United Way Pledge Form - United Way Of The Mid-South printable pdf download

me in writing. If applicable, I authorize

pt confidential. United Way of the

Pledge Form

ETHER.

FOLLOW THESE 3 EASY STEPS TO MAKE A DIFFERENCE IN YOUR COMMUNITY!

1. Complete Donor InformatIon

(please print)

10/28/15 9:43 AM

My name has changed. Previous name:

Mr.

Mrs.

Ms.

Dr.

FIRST NAME

M.I.

LAST NAME

HOME ADDRESS

CITY

STATE

ZIP CODE + 4

EMPLOYER

PHONE

Please let us know how long you have supported United Way:

years

I am under 40 and interested

I am a member of

I am interested in helping

I am interested in learning

in joining the United Way

Organized Labor.

United Way’s “Women

about Youth United Way’s

Emerging Leaders Society.

United” work next year.

Leadership Program.

2. DeCIDe how muCh to ContrIbute anD how to gIve

Be a Leadership Giver!

Be a Tocqueville Society Giver!

Annual gifts of $500 - $9,999 are listed on our website.

Annual gifts of $10,000 or more are listed on our website.

Other Payment Options

I want to contribute a specific amount each pay period:

Cash $

enclosed

$75

$50

$35

$25

Other

Personal Check Enclosed

$20

$15

$10

Credit Card (Note: Your card company may apply a fee)

Total Annual Gift $

Stocks/Securities

(Please Call 901.433.4374)

AND/OR

Bill me: Monthly / Quarterly (circle one) For $

I want to contribute a one-time gift in the amount of:

Expiration Date

Visa

MasterCard

AMEX

Discover

Card#

Security Code

Please print your name as you would like it to appear on our website (Examples: Mr. and Mrs. John Doe or John and Jane Doe)

3. SIgn anD Date

OPTiONAL: Donor Designation Information

Please see back of form for guidelines and criteria

Check here to remain anonymous on public listings (signature still required)

about designating your donation.

Check here if you prefer not to receive gift acknowledgement or other communication

I would like to designate my donation to:

United Way’s Community impact Fund, which

impacts local poverty through its work to improve

Signature

Date

education, financial stability, & health.

(required)

Partner Agency

I authorize my employer to deduct the necessary amount(s) from each paycheck. I understand this authorization will continue

unless otherwise specified by me in writing. If applicable, I authorize United Way of the Mid-South to make a charge to my

Name

credit card as indicated above for the amount stated. I understand all personal information will be kept confidential. United

Address

Way of the Mid-South does not provide goods or services as a whole or partial consideration for any contribution.

City, State, Zip

United Way is working to make a positive impact on people’s lives in your community. To do that,

Other 501(c)(3) Agency

we need to know in which county your community is located. If you would like to designate your

donation to a county other than the county of your employment, please mark here:

Name

Address

Crittenden

DeSoto

Fayette

Lauderdale

City, State, Zip

Shelby

Tate

Tipton

Tunica

FRONT COPY: TO YOUR ORGANIZATION’S PAYROLL OFFICE

SECOND COPY: TO UNITED WAY

BACK COPY: YOUR COPY— VERY IMPORTANT FOR TAX RECORDS

United Way Pledge Form - United Way Of The Mid-South

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