Pledge Form - United Way

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Pledge Form
3001 Clearwater Road, Suite 201, St. Cloud, MN 56301
320.252.0227 .
BE THE
.
DONOR INFORMATION
Step 1:
FIRST NAME
MI
LAST NAME
AGE
18 - 25
HOME ADDRESS
CITY
STATE
ZIP
26 - 35
36 - 45
HOME
46 - 55
CELL
PHONE
PERSONAL EMAIL
WORK
56 - 65
66+
EMPLOYER
I am retiring
in the next
12 months
SIGNATURE
DATE
Our privacy pledge to you: Information shared with us is used only to properly credit your contribution. We NEVER sell, rent or exchange your information with anyone without your permission.
GIVE
Step 2:
LEADERSHIP DONORS:
Leadership Gift ($1,000+)
DONOR MATCH AVAILABLE
Joint Leadership Gift
Thanks to generous community support, every donor who increases their
donation by at least $24 from last year will be matched.
CO-DONOR
P
D
AYROLL
EDUCTION
Total: $__________
CO-DONOR EMPLOYER
One dollar more per pay period - based on your last year’s donation
(available for match gift)
CO-DONOR AMOUNT
I would like to contribute $________ more per pay period - based on your
last year’s donation (available for match gift)
NAME RECOGNITION FOR PUBLICATIONS
Gift amount: (per pay period)
$25
$15
$5
I prefer to remain anonymous. By checking here, my name will not be
$20
$10
$______
published.
Number of Pay Periods (circle one):
12
24
26
52
other
Additional Information:
B
M
ILL
E
Total: $__________
($50 minimum)
I am a Loyal Contributor (giving for 10 years or more):
I would like to contribute $________ more
I have been supporting (any) United Way for _________ number of years.
($24 minimum increase required for match gift)
I have included United Way of Central Minnesota in my will or estate plan.
I would like to learn more about the benefits of making a planned gift.
annually
monthly
START DATE
quarterly
(deductions will begin in January unless indicated)
ADVOCATE
Step 3:
. . .
C
C
ASH or
HECK
I care about:
Total: $__________
Reducing Homelessness
cash
check
(payable to United Way of Central Minnesota)
Providing Access to Food
Increasing Financial Stability
($24 minimum increase required for match gift)
Engaging Youth in Quality Out of School Time
Accessing Early Learning/Early Literacy
C
C
A
B
P
REDIT
ARD or
UTOMATIC
ANK
AY
Total: $__________
VOLUNTEER
Step 4:
. . .
I would like to contribute $________ more
($24 minimum increase required for match gift)
Please inform me about upcoming volunteer opportunities
To donate by Credit Card or Automatic Bank Pay: Please list a daytime phone
number where a staff member can reach you to collect your information.
Visit for more than 200 local volunteer opportunities.
No goods or services have been received in exchange for your donation.
DAYTIME PHONE
BEST TIME TO CALL
CAMPAIGN ADVOCATE ONLY:
(to be completed by employer)
X
=
# pay periods
pledge amount
total annual gift
check #
date

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