Electronic Pledge Form United Way Of East Central Iowa
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1UNITED WAY OF EAST CENTRAL IOWA PLEDGE FORM
DONOR INFORMATION
THANK YOU!
STEP 1
Gender: o Male o Female
Birth Date (mo/year):
/
o I have been a United Way donor for 25 years
Name (first, middle, last): ______________________________________________________________
or more (Diamond Donor).
o Home
Address: _____________________________________________________________________
o Work
o I am a union member.
Billing Address: ______________________________________________________________________
Union Name: ________________________
(if different from above)
Local #: _____________________________
City, State, ZIP: ______________________________________________________________________
o Home
Phone: _______________________________________________________________________
o Work
I am planning on retiring in the next
o Cell
12 months
Company name: _____________________________________________________________________
E-mail: _____________________________________________________________________________
I would like my donation to be anonymous
o
Check the box if you DO NOT want to receive our monthly newsletter.
MY GIFT TO MY COMMUNITY
STEP 2
o Volunteer Hours
I want to contribute the following amount per
o Easy Payroll Deduction
pay period :
In addition to my donation, I pledge to volunteer
My total annual gift is: $ _________________
in the community for next year approximately:
o $5
o $50
# of pay periods per year: ________________
o
o $10
o $100
25 hours
o
o
50 hours
100+ hours
o $20
o Other ( _____________ )
o I would like information about volunteering.
o One-Time Gift
o Credit Card / Debit Card
o Cash/Check Enclosed
o Visa o Mastercard o Discover o American Exp.
Check #
My total gift is: $______________
Card # ______________________
Check date:
Exp. date ___________________________
o Stock/Securities (To facilitate your stock transaction,
CVC/CVV Code:
please call 398-5372 x840.)
o Recurring Gift
Additional Gift Options
Please deduct my gift:
o Credit Card / Debit Card
o Monthly
o Visa o Mastercard o Discover o American Exp.
I would like information about
My total annual gift is: $
o Quarterly
Card # ______________________
including United Way in my will,
Exp. date ___________________________
o Semi-Annually
trust or estate plans.
CVC/CVV Code:
I have included United Way in
my will or estate plan.
I hereby authorize United Way of East Central Iowa to initiate this recurring transaction the first month after my information
is recieved. This recurrence will continue until paid in full.
Signature ______________________
Date ___________________________________
o Bill Me
Please bill me:
(Please allow 90 days
for processing)
o Monthly o Quarterly o Semi-Annually
(Please verify correct billing address in step one.)
My total annual gift is: $ ________
LEADERSHIP SOCIETIES
STEP 3
Please check all that apply:
My gift is combined with that of:
o Labor Leadership Society
o Alexis de Tocqueville Society ($10,000+)
Company:
(Union Members $350+)
o T.M. Sinclair Society ($1,250 - $9,999)
Name:
o Young Leaders Society
o William B. Quarton Society ($500 - $1,249)
(Age 40 and under, $250+)
Please list me/us in materials as:
o Women’s Leadership Initiative
A minimum of $500 must be designated to WLI.
Name: ___________________________________________________
If more than $500, please specify
amount here: $
SIGNATURE
STEP 4
(REQUIRED FOR PROCESSING)
Signature __________________________________________________________________
Date ___________________________________
No tangible benefit was received in exchange for this contribution unless specifically noted. Gifts made to United Way of East Central Iowa are tax deductible
within the limits of the current law. If you’ve contributed via payroll deduction, you will not receive a tax letter since your pay stub will serve as tax documentation.
United Way of East Central Iowa • 317 Seventh Avenue SE, Suite 401, Cedar Rapids, IA 52401 • 319-398-5372 •
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YELLOW COPY: EMPLOYER
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Parent category: Financial