Fillable United Way Of Dane County Pledge Form printable pdf download

2016 United Way of Dane County Pledge Form

0001

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. _______________________________________________________________________________________________________________________

First

Middle

Last

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.

Month/Day/Year

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 ___________________________

(Year)

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

Amount:

$10

$30

$ ________

X pay periods

________

(monthly)

(semi-monthly)

(every other week)

o Payment Enclosed:

Cash

Check

Make checks payable to United Way of Dane County

o Credit Card:

Visa

MasterCard

Discover

American Express

Card #: ____________________________________________________________________________________Exp Date: __________________

o Bill Me:

Quarterly beginning in __________________

Monthly beginning in _________________________

One billing _______________________

(month/year)

o Stock: Please call (608) 246-4365 for more information on donating stock.

TOTAL GIFT

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 ________________

(mm/dd/yy)

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.

Authorization

THANK YOU!

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.

Optional

I prefer that a portion of my gift advance these Agenda for Change goals:

Partnership

Education

Income

Health

$ ________ 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: # ____________

United Way Of Dane County Pledge Form

Related Articles

Related forms

Related Categories