United Way Pledge Form
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1
2United Way Pledge Form
MY INFORMATION
(PLEASE PRINT)
MR/MRS/MS/DR
FIRST NAME
MI
LAST NAME
SUFFIX
MR/MRS/MS/DR
SPOUSE’S FIRST NAME
MI
SPOUSE’S LAST NAME
SUFFIX
PREFERRED EMAIL ADDRESS (We never share donor information with outside groups.)
HOME ADDRESS
-
-
CITY
o
o
o
STATE
ZIP
PREFERRED PHONE
HOME
WORK
MOBILE
EMPLOYER NAME
MY PLEDGE (
PLEASE SELECT PAYROLL DEDUCTION OR A ONE-TIME GIFT)
o One-Time Gift to be paid by:
o Easy Payroll Deduction: I want to contribute
My Total
the following amount per pay period.
Annual Gift is:
o Cash
o $50 o $40 o $25 o $10 o $5
o Personal Check (enclosed) Check #________
$________________
o Credit Card (Visa/MC/AmEx/Discover)
o Other $_______________
$50 minimum, include billing address above
CC# _________-_________-_________-_________
My pay period is:
Expiration Date_________ /_________________
o Weekly (52/year)
Security Code (from back of card) ______
o Every two weeks (26/year)
o Bill my home address ($250 minimum. Please
o Twice a month (24/year)
include home billing address above)
o Other _______________
OPTIONS
TO GIVE TO OUR COMMUNITY’S MOST URGENT NEEDS
o Community Fund $________________________
The most powerful way to contribute. Dollars are invested by volunteers to meet the critical issues in our community.
o I wish to give THROUGH United Way
I would like to designate my gift (see back of form). $50 minimum pledge.
Designation code ______________
Initiative, Agency Partner, Affinity Group or other United Way
Amount $_______________
MY PREFERENCES
CHECK ALL THAT APPLY
o My contribution of $1,000 or more, alone or combined with my spouse, qualifies me as a Leadership Giver. Please list me/us in the
Leadership Directory as: ________________________________________________________.
o Please do not list me.
o My gift of $1,000 or more qualfies me for membership in the Women’s Leadership Council
o I have remembered United Way of Allen County in my estate plans or wish to do so.
o I have been giving to United Way since _______________________.
PLEASE SIGN HERE
TO AUTHORIZE YOUR PLEDGE
Signature
_________________________________________________________________________________
Date
_______________________
No goods or services were provided in exchange for this donation. In order to protect your privacy, United Way of Allen County will not release your name to other parties unless otherwise
authorized. This contribution will continue unless revoked or modified by donor.
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