United Way Pledge Form
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1
2REACH OUT A HAND TO ONE AND INFLUENCE THE CONDITION OF ALL
LIVE UNITED
TM
United Way Pledge Form
Want to see how your
contribution is making
MR/MRS/MS/DR
FIRST NAME
MI
LAST NAME
a difference?
HOME ADDRESS (For credit card charges, address listed must be your billing address.)
CITY
Follow the impact of
your contribution
STATE
ZIP
HOME PHONE
WORK/CELL PHONE
and learn about
opportunities to give, advocate and
COMPANY NAME
volunteer throughout the year by
entering your email address at left.
EMAIL ADDRESS
PLEASE SELECT PAYROLL DEDUCTION OR A DIRECT GIFT
o
o
o
o
EASY PAYROLL DEDUCTION
DIRECT GIFT
BILL ME (minimum $50 pledge)
MY GIFT OF $1,000 OR MORE
qualifies me for membership in
My total annual gift
❍
Annually
❍
Quarterly
the Leadership Giving Society.
AMOUNT $
AMOUNT $
AMOUNT $
AMOUNT $
Direct gift to be paid by:
Cash
❍
A.
I want to contribute the following
Please list my/our name(s) as follows:
❍
amount each pay period:
Personal check (enclosed)
❍
BEGINNING ON (MM/DD/YYYY)
❍
$50
❍
$25
❍
$10
❍
$5
Money order (enclosed)
❍
_____________________________________________
o
CREDIT CARD (minimum $25)
Cashier's Check (enclosed)
❍
I prefer that my gift remain anonymous.
Other $
❍
❍
VISA
❍
MasterCard
Check #_______________
B.
I pledge
% of my salary, for
(Please make payable to
CARD NUMBER
Fox Valley United Way)
a gift of
TOTAL $
TOTAL $
EXP. DATE (MM/YY)
PLEASE CHOOSE HOW YOU WANT TO INVEST IN YOUR COMMUNITY
option A
COMMUNITY ACTION FUND – INFLUENCE THE CONDITION OF ALL
o
AMOUNT $
The most powerful way to invest your contribution. Your donation will be added to others to support dozens
of social service agencies in Kane and Kendall counties.
option B
EDUCATION
INCOME
HEALTH
o
o
o
Helping children and youth achieve their
Helping families become financially stable
Improving people’s health
potential through education
and independent
AMOUNT $
AMOUNT $
AMOUNT $
option C
SPARK – STRONG, PREPARED AND READY FOR KINDERGARTEN
o
AMOUNT $
An Aurora early childhood collaboration aimed at ensuring that all of Aurora’s young children have access to quality
early learning programs that strengthen their school readiness skills.
option D
RESTRICTED CONTRIBUTION
o
AMOUNT $
I wish to direct my gift to another United Way or a specific Fox Valley United Way partner agency:
See list of Fox Valley United Way Partner Agencies on the back side of the form.
Thank you for your contribution.
Signature
Date
Please check the accuracy of all your entries. No goods or services were provided in exchange for this contribution. Please keep a copy of this form for your tax records. You will also need a copy of
your pay stub, W-2 or other employer document showing the amount withheld and paid to a charitable organization. Consult your tax advisor for more information.
WHITE – FOX VALLEY UNITED WAY
YELLOW – EMPLOYER OR EMPLOYEE
8/16
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