United Way Pledge Form - State Of North Carolina

UNITED WAY

GREAT THINGS HAPPEN

PLEDGE FORM

WHEN WE LIVE UNITED

PLEASE PRINT LEGIBLY.

(*required)

DR. / MR. / MS. / MRS. FIRST, MIDDLE INITIAL & LAST NAME* ___________________________________________________

(circle one)

GENDER (circle one) FEMALE MALE

HOME ADDRESS* _____________________________

CITY/STATE/ZIP* ______________________________

EMPLOYER _________________________________________

EMPLOYEE ID _______________________________________

HOME PHONE _______________________________

CELL PHONE ________________________________

WORK PHONE _______________________________________

PERSONAL EMAIL _____________________________

WORK EMAIL _______________________________________

METHOD OF PAYMENT

$

MY TOTAL PLEDGE AMOUNT IS

Please select payroll deduction or other payment option.

EASY PAYROLL DEDUCTION

PAY BY CHECK or CASH

m

m

Attach your check made out to: United Way of Forsyth County. Total Annual Gift Amount $_____________

A. Select your payroll frequency:

m Weekly (52)

m Bi-weekly (26)

DIRECT BILL

m

(complete A – D) Minimum donation of $100 or more. Home address is required.

m Semi-monthly (24) m Monthly (12)

m

m

m

m

A. Select one:

Monthly (12)

Quarterly (4)

Semi-annually (2)

Once (1)

B. Amount per pay period:

B. Installment Contribution $_____________ C. Billing Start Date___________

m $10

m $25

D. Total Annual Gift Amount (AxB) = $______________

m $50

m $100

CREDIT CARD

m

(complete A – E)

m Other ______

Minimum donation of $100. Also available at

A. Card #_______________________________________Exp. Date___________

C. Total Annual Gift Amount

m

m

m

m

B. Select one:

Monthly (12)

Quarterly (4)

Semi-annually (2)

Once (1)

(AxB)= $______________

C. Installment Contribution $_____________ D. Billing Start Date___________

SINGLE PAYROLL DEDUCTION

m

E. Total Annual Gift Amount (BxC) = $______________

$______________on__________

Stocks or Securities Transfer

m

For assistance, please call United Way at 336-723-3601.

(Total Annual Gift Amount)

(Date)

SELECT AND COMPLETE ALL THAT APPLY.

m I am a Loyal Contributor. I have been investing in my community with United Way since_________.

m My contribution is part of a household gift. Combine my pledge with my spouse/partner:

Spouse/Partner Name_______________________________Employer____________________________________

m Please list my/our name(s) as follows in publications______________________________________________________

m I prefer that my/our gift remain anonymous.

LEADERSHIP GIVING

Select all that apply. Please see reverse of form for step-up programs and information on leadership giving contribution requirements.

m Tocqueville Leadership Society

m Leadership Circle

m Women’s Leadership Council

m Young Leaders United

($10,000+ contribution)

($1,000+ contribution)

($1,000+ contribution)

(ages 18-40, $250+ contribution)

My Signature

Date

(Signature and date are both required for all methods of payment)

THANK YOU FOR INVESTING IN YOUR COMMUNITY

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. A copy of this organization’s solicitation license is available from the state at 1-800-830-4989. This license is not an endorsement by the state.