United Way Of Dane County Pledge Form

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2016 United Way of Dane County Pledge Form
2059 Atwood Avenue Madison, WI 53704 (608) 246-4350
My Information
Please print clearly. Your personal information is kept confidential and will not be sold or shared at any time.
o Mr. o Mrs. o Ms. o Dr. _______________________________________________________________________________________________________________________
Home Address: _________________________________________________________________________________________________________________________________
City: _______________________________________ State ___________ ZIP: ________________________ Cell Phone: ______________________________________________
Employer: ___________________________________________________________________ Employee No.: _______________________________________________________
Date of Birth: ________________ Personal Email: ______________________________________________________________o I do not want to receive the United Way e-newsletter.
Race/Ethnicity: o Asian or Pacific Islander o Black or African American o Hispanic or Latino o Native American or American Indian o White o Other: _____________________________
o United Way Loyal Contributor. Please recognize me as a United Way Loyal Contributor because I have been giving for 25 years or more. I have been giving since ___________________________
o I am interested in receiving information about being involved as a retiree.
My United Way Investment
(Please select method of payment)
Not sure what to pledge? Please consider your 2015 pledge + 10%, 1% of your annual income or 1 hour’s pay per month.
o Payroll Deduction: Amount per pay period X pay periods per year = total annual gift
$ ________
X pay periods
(every other week)
o Payment Enclosed:
Make checks payable to United Way of Dane County
o Credit Card:
American Express
Card #: ____________________________________________________________________________________Exp Date: __________________
o Bill Me:
Quarterly beginning in __________________
Monthly beginning in _________________________
One billing _______________________
o Stock: Please call (608) 246-4365 for more information on donating stock.
Your first-time gift of $25 or more or your gift increase over last year by $25 or more automatically enters you into
our 2016 Give United Get Healthy sweepstakes. Pledge forms must be received by October 14, 2016.
Leadership Giving
(Please check all that apply)
Your gift can be combined with a household member to be recognized at any of the leadership levels below. To make a household leadership gift, please fill out the following lines:
Household member’s name: ____________________________________________________ Household member’s workplace: _______________________________________
o Key Club. I (or combined with a household member) contribute $750 or more. Please recognize my household gift at the following giving level:
Copper ($750—$1,124)
Silver ($1,500—$2,999)
Platinum ($5,000—$7,499)
Bronze ($1,125 —$1,499)
Gold ($3,000—$4,999)
Diamond ($7,500 —$9,999)
Please send me a Key Club recognition pin
Please do not list my name in the Key Club Directory
o Rosenberry Society. I (or combined with a household member) am a young leader under age 30 and contribute $250 or more OR age 30-40 and contribute $500 or more. Please add birthdate ________________
o Women’s Leadership. I prefer to give $ _________ of my total gift to this year’s Women’s Leadership initiative, Schools of Hope Tutoring Program. Recognition begins at $100. (1244)
o Tocqueville Society. Please send me information on the Tocqueville Society, United Way’s program for households giving $10,000 or more annually.
o United Way Foundation. I want to invest in our community’s future. Please send me information on including United Way of Dane County Foundation, Inc. in my will or other estate plans.
Your signature (required)
No goods or services were provided in consideration of this gift. United Way of Dane County will provide a financial statement upon request. Please make a copy of this form for tax purposes.
I prefer that a portion of my gift advance these Agenda for Change goals:
$ ________ Nonprofit agencies and volunteers are strong
$ ________ Nurturing young children and families (51)
$ ________ More people are on pathways out of poverty (55)
$ ________ People’s health issues are identified
partners in achieving measurable results (56)
and treated early (52)
$ ________ Helping kids succeed in school (50)
$ ________ Reducing family homelessness (53)
$ ________ Innovation fund to accelerate
$ ________ Keeping the elderly and people with
learning in emerging strategies (57)
disabilities in their homes (54)
I authorize release of my name to these agencies for acknowledgement of my gift.
I prefer to give a portion of my gift to United Way, Community Health Charities or a specific agency (see back of pledge form for agency code numbers).
# __________________ $ ________________
# __________________ $ ________________
# __________________ $ ________________
# __________________ $ ________________
Other 501(c)(3) nonprofit agency or other United Way
Agency _________________________________________________ $ _______________ Agency Address ________________________________________________ City/State/Zip _____________________________________
I wish to exclude this agency from receiving any of my gift: # ____________


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