UNITE D WAY MANITOWOC COUNTY, INC.
PLEDGE FORM
q
Loyal Contributors Program
I have been contributing to
MR/MRS/MS/DR
FIRST NAME
MI
LAST NAME
SUFFIX
United Way for 10 years or more. I
have been giving since
HOME ADDRESS (For direct bill gifts, address listed must be your mailing address.)
CITY
(Year)
Male
Female
q
❍
❍
Volunteer Program
Please contact me with information about
STATE
ZIP
HOME PHONE
DATE OF BIRTH
GENDER
volunteering.
q
I plan on retiring in the next few years.
EMAIL ADDRESS
COMPANY NAME
MY UNITED WAY INVESTMENT.
TOTAL ANNUAL GIFT $
LEADERSHIP GIVING
MY GIFT qualifies me for membership in the
PLEASE SELECT ONE OF THE PAYMENT OPTIONS LISTED:
following Leadership Giving societies...
TOCQUEVILLE SOCIETY
($10,000 or more)
q
q
CASH/CHECK ENCLOSED
PAYROLL DEDUCTION
LEADERSHIP CIRCLE
q
Amount per pay period $
BILL ME
($25 Minimum)
Gold $5,000-$9,999
•
Silver $2,500-$4,999
To pay later by credit card or personal check,
•
Number of pay periods
Bronze $1,000-$2,499
your mailing address is required.
•
q
ONE-TIME PAYROLL DEDUCTION
Quarterly
Friends $500-999
•
(Mar/Jun/Sept/Dec)
❍
Yearly
(Jan)
❍
WOMEN'S LEADERSHIP COUNCIL
($500 or more)
PLEASE CHOOSE HOW YOU WANT TO INVEST IN YOUR COMMUNITY.
option A
q
INFLUENCE THE CONDITION OF ALL.
United Way Community Action Fund.
The most powerful way to invest your contribution.
option B
q
q
q
EDUCATION
INCOME
HEALTH
Helping children and youth
Helping families become
Improving People’s Health
achieve their potential through education
financially stable and independent
AMOUNT $
AMOUNT $
AMOUNT $
q
q
I prefer that my gift remain anonymous.
Combine my gift with…
q
Do not mail a gift acknowledgement.
SPOUSE NAME
Signature
COMPANY NAME
Thank you for your contribution through the United Way campaign. 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.
21 East Waldo Blvd
Please check the accuracy of all your entries.
Manitowoc, WI 54220
Thanks for investing in United Way.
(920) 682-8888
WHITE - United Way
YELLOW - Employer
PINK - Employee