CFC Pledge Form

2020 Combined Federal Campaign

OPM Form 1654-B

FEDERAL RETIREE PLEDGE FORM
Please use black ink. Sections marked with

* are mandatory.

Online pledges are accepted through Jan. 15, 2021, by visiting opm.gov/ShowSomeLoveCFC. Keep a copy of this form before
sending it to: CFC Processing Center, P.O. Box 7820 Madison, WI 53707-7820. Checks are accepted, however do not send cash. CFC
organizations do not provide goods or services in whole or partial consideration for any contributions made to the organizations via
this pledge.

Donor Information ( required )
1. Primary Email Address *

2. Secondary Email Address

3. Name * (first name)

* (last name)

4. Retiree Type - Pay Service (required for annuity deduction)

5. Home ZIP Code or APO *

□ Military - DFAS

Civilian - OPM

Judiciary

Pledge Information (required)
6. Allotment Source *

7. Amount Per
Deduction

8. Total Annual Gift *

(automatically calculated
based on the amount per
deduction multiplied by 12)

You must select one or more 2020 CFC-approved charities or
federated groups to receive your donation. Confirm each charity’s
five-digit code in the online charity search or charity listing and
enter it along with the total dollar amount you want each charity to
receive below. The total annual gift from the left must match the
total pledged to charities below.

$____________________

If you would like to donate to more than five charities, please visit
opm.gov/ShowSomeLoveCFC to complete an online donation or
attach another copy of this form with the total annual contribution
amount should appearing on copy 1 of X.

Annuity
SSN (only required if electing)

-

-

$_____________________
Monthly (x12)

Check
Make checks payable to “Combined
Federal Campaign” and attach to this form.

N/A

$_____________________

Check Amount

10. Authorization *
If I chose annuity deduction as my payment source, I hereby authorize any agency of the
United States government from which I may be retired during 2021 to deduct the amount(s)
shown above from my annuity each payment period during the calendar year. These
deductions will start with the first annuity payment period following Jan. 15, 2021 and ending
with the last allotment period that includes Jan. 15 of the following year. I authorize the
government to pay the amounts deducted to the Combined Federal Campaign. I understand
that this authorization may be revoked by me in writing at any time before it expires. I also
acknowledge that I have the right to receive a notification if the amount(s) scheduled to be
transferred differ(s) from the amount(s) displayed above. If I chose check, I hereby authorize
Give Back Foundation on behalf of the Combined Federal Campaign to process my paper
check as an electronic funds transfer (EFT) for the payment amount elected.

Signature: _________________________________________

9. Charity Designation *

Date: ______________________

CFC Charity Code

Annual Amount

___ ___ ___ ___ ___

$__________________

___ ___ ___ ___ ___

$__________________

___ ___ ___ ___ ___

$__________________

___ ___ ___ ___ ___

$__________________

___ ___ ___ ___ ___

$__________________

Total Annual Contribution

$__________________

Information Release (optional)
11. By checking each box below, I authorize the CFC to release my name and the following to my designated charity(ies):
My pledge amount
My home address (if opting to release your information, please provide your home address below.)
My email address (from above)
Home Address

City

State

ZIP Code

Individuals may pledge online at opm.gov/ShowSomeLoveCFC and may contact the CFC Help Desk Monday through Friday from 8 a.m.
until 6 p.m. Central Time at 800-797-0098 (toll-free) or 608-237-4898 (local/international) with questions about the pledge process.

Instructions for Properly Completing Form OPM 1654-B
1.

Primary Email Address: This is your work email address.

2.

Secondary Email Address: (Optional) This is your secondary email address. .

3.

Name: Print your legal names legibly here.

4.

Retiree Type – Pay Service: (Required for annuity deduction) Select your retiree type or pay service here.

5.

Home ZIP Code or APO: Enter the ZIP code or APO/FPO of the location where you currently reside.

6.

Allotment Source: Check the box either for annuity or check. You only have to provide your Social Security number if you are electing to pledge via annuity
deduction.

7.

Amount Per Deduction: For annuity deduction, enter your amount pledged per deduction and select the frequency of your pay periods.

8.

Total Annual Gift: For annuity deduction, multiply the amount pledged per deduction by the frequency of your pay periods (x12). For check, enter the check
amount.

9.

Charity Designation: You must select one or more of the 2020 CFC-approved charities or federated groups to receive your monetary pledge. Confirm each
charity’s five-digit code in the online charity search or charity listing. Identify your selected charities by entering their corresponding five-digit code along with
the total dollar amount you want each charity to receive. The total annual gift from the left must match the total pledged to charities on the right. If you would
like to donate to more than seven charities, please pledge online or use multiple paper pledge forms with the total annual contribution amount appearing on
copy 1 of x.

10. Authorization: Sign and date to authorize any agency of the United States government from which you may be retired during 2021 to deduct the amount(s)
shown above from your annuity each payment period during the calendar year. These deductions will start with the first annuity payment period following
Jan. 15, 2021 and ending with the last allotment period that includes Jan. 15 of the following year.
11. Information Release: (Optional) Select box(es) to authorize the CFC to release your name, email, pledge amount or home address to your designated
charity(ies). This information is not required.

Combined Federal Campaign Privacy Act Statement
Pursuant to 5 U.S. C. 522a(e)(3), this Privacy Act Statement informs you why OPM is requesting information on this form.
AUTHORITY: OPM is authorized to collect the information on this form based upon the authority provided in Executive Order (EO) 12353 (March 23, 1982), as
amended by EO 13743 (October 13, 2016), and 5 CFR 950 (January 1, 2017). In addition, Executive Order 9397 (November 22, 1943), as amended by EO 13478
(November 18, 2008), permits us to collect your Social Security number (SSN).

PURPOSE: The information you provide is primarily collected and used by OPM to accurately receive, process, acknowledge, and account for your donation to the
Combined Federal Campaign (CFC); and to make payments to the charitable organizations to which you choose to donate.

ROUTINE USES: The information we collect from you may be disclosed as a “routine use” to your payroll service provider, if you have chosen to make a recurring
gift via payroll deduction; or to your credit card company, bank, or other financial institution for a one-time or recurring gift (using the CFC’s online option) via
credit card, electronic check, or automatic deduction from your financial account. With your authorization, we may also share the information you provide to us
with local, national, or international charitable organizations or federations. In addition, we may share your information as a “routine use” with other external
entities, such as law enforcement or state and federal tax authorities, when the disclosure is necessary to investigate a violation or potential violation of civil or
criminal law. A complete list of routine uses can be found in the system of records notice titled
“Central-20 National CFC System of Records.”

CONSEQUENCES OF FAILING TO PROVIDE INFORMATION: Providing this information, including your SSN, is voluntary; however, without your signature and
all of the information requested, it may not be possible for us to make this gift on your behalf, and we may suspend this pledge. In addition, if you do not provide
any of the requested information, we may not be able to process your request for an annuity deduction. If you are making a one-time, lump-sum gift and,
therefore, not using the annuity deduction method of payment, you are not required to furnish your SSN.
PUBLIC BURDEN STATEMENT: We think providing this information takes an average of 30 minutes per response to complete, including the time for reviewing
instructions, getting the needed data, and reviewing the completed information collection title. Send comments regarding our estimate or any other aspect of the
information collection, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), OPM Forms Officer (3206-0271),
Washington, D.C. 20415-7900. The OMB number 3206-0271 is valid. OPM may not collect this information, and you are not required to respond, unless this
number is displayed.