2016 STATE PLEDGE FORM SIGN HERE NAME (Last, First, Middle

When you give to Hawaii Island United Way your donation stays right here on Hawaii Island. Mahalo.
2016 STATE PLEDGE FORM
P. O. Box 745 • Hilo, Hawaii 96721 • (808) 935-6393
1
MY INFORMATION ~ All information must be complete.
 Mr.
 Ms.
 Other _______
(Please type or print clearly.)
XXX-XXSS# _____________________
 Suffix _______
PR-DIST. NO.:______________________
NAME (Last, First, Middle Initial):_____________________________________________ Job Title: ________________________ AGT:001
Home/Billing Address: ____________________________________________City/State: _____________________Zip:______________
Day Phone: ___________________________________
2
E-mail Address:____________________________________________________

MY TOTAL PLEDGE AND HOW I CHOOSE TO PAY ~ Your 2016 pledge will be distributed in 2017.
Payroll Deduction: I authorize the Comptroller to deduct the following amount $___________ per
month beginning January 2017. Last Four Digits Of SS# Required For Payroll Deduction.

Cash
 Check
Total Annual
Payroll Deduction
$
Check #: ___________________ Check Date: ____________
Cash/Check
$
(Payable to Hawaii Island United Way.)
* Bill Me:  one-time $______  quarterly $______  semi-annual $______
(Minimum $25 for Bill Me options.)
Total Billing
$
* Credit Card: I authorize a  one-time  monthly  quarterly charge to my credit card
Account #________________________________ Zip Code: _____________ Exp. Date _____________
*Monthly & Quarterly credit card/billing transactions will begin January 2017.
Total Credit Card
$
MY TOTAL PLEDGE
 Please check this box if you would like your name withheld from publication.  Yes! I would like to volunteer with HIUW!  Yes! Please email me updates.
 Yes! Please send me Planned Giving Information.
$
* Section 1 must be completed.
3
SIGN HERE
_________________________________________________________
SIGNATURE REQUIRED
N
(No goods or services of more than nominal value given in return for this contribution.)
Dollars per month
12 Payments
$5
$60
$10
$120
$20
$240
$50
$600
$100
$1,200
$250
$3,000
PAYROLL DEDUCTION GIVING GUIDE
Payroll deduction is a convenient way to give. Giving is a
personal decision and is voluntary. The following may be used as
a guideline. Whatever amount you choose to give – Thank You.
MAHALO FOR YOUR GIFT.
Please contact Hawaii Island United Way at 808-935-6393 for
information, referrals, or to volunteer and offer assistance.
Original Signature Required.
NO PHOTOCOPIES OF SIGNATURES ACCEPTED.
Contact Hawaii Island United Way
at 935-6393 for additional forms.
HIUW – Original • DONOR - Please make copies for your records.
OPTIONAL ~ I would like to designate to the following Agency / Program:
 Specific Community Initiative Areas:
 Specific HIUW Partner Agency / Program:
Education $_________ 1._ ___________________________ $__________
Income $_________ 2.____________________________ $__________
Health $_________ 3_____________________________ $__________
 A 501(c)(3) Non-Profit Agency: (Minimum $50 donation. Admin Fee applies).
__________________________________________ $______________
 P lease check this box if you would like acknowledgement from the agency you designated to.
Five United Way Agencies...
Kauai United Way
Aloha United Way (Oahu)
How your investment grows...
1
Trained HIUW volunteers
meet with partner agencies to
review programs & services
needed on Hawaii Island.
2
HIUW distributes your
donations to partner agencies,
investing in specific programs
with measurable results.
3
Program outcomes are routinely
measured for "Results we can see!"
By tracking successes, we are also
better able to address the changing
needs of our community.
Friendly Isle United Fund
(Molokai)
Maui United Way
Hawaii Island United Way
(Big Island)