me in writing. If applicable, I authorize
pt confidential. United Way of the
FOLLOW THESE 3 EASY STEPS TO MAKE A DIFFERENCE IN YOUR COMMUNITY!
1. Complete Donor InformatIon
10/28/15 9:43 AM
My name has changed. Previous name:
ZIP CODE + 4
Please let us know how long you have supported United Way:
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
United Way’s “Women
about Youth United Way’s
Emerging Leaders Society.
United” work next year.
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:
Personal Check Enclosed
Credit Card (Note: Your card company may apply a fee)
Total Annual Gift $
(Please Call 901.433.4374)
Bill me: Monthly / Quarterly (circle one) For $
I want to contribute a one-time gift in the amount of:
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
education, financial stability, & health.
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
credit card as indicated above for the amount stated. I understand all personal information will be kept confidential. United
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:
City, State, Zip
FRONT COPY: TO YOUR ORGANIZATION’S PAYROLL OFFICE
SECOND COPY: TO UNITED WAY
BACK COPY: YOUR COPY— VERY IMPORTANT FOR TAX RECORDS