1 My Personal Information 2015 Pledge Form Company Name Prefix First MI Last 3 Home Address City State Phone Email 2 o ZIP My United Way Investment Please select a method of payment from the following: EASY PAYROLL DEDUCTION Amount to be deducted from each paycheck: o$5 o$10 o$20 o$50 Other ($_________) My pay period is: o Weekly (52) o Bi-Weekly (26) o Semi-Monthly (24) o Monthly (12) o Other (___) Total Investment $____________ o United Way of Campbell County ONE-TIME PAYROLL DEDUCTION Amount $___________________ o DIRECT GIFT Amount $___________________ o Cash (enclosed) o Check (attached) Ck#________________ o Credit Card (for your security please call the office at 307.686.0902 or visit www.unitedwaycampbellcounty.org to make your pledge) All funds will go directly to the Community Fund. Otherwise, you may designate your investment of $50 or more to another 501(c)(3) organization____________________________________________________ Designated gifts to non-partner agencies will incur a 10% fee. Cottonwood Circle Make the biggest impact possible - become a Cottonwood Circle Level Donor. By giving $14.42 a week - only $2.06 a day - you can create powerful, positive change in people’s lives. Invest in your community at a level that is significant and meaningful to you: o Combine gift with my GREEN $750-$1,500 spouse. Spouse’s name BRONZE $1,501-$3,000 and workplace. _______________________ SILVER $3,001-$5,000 _______________________ GOLD $5,000+ o I have a plaque and need a new leaf. o No o Yes - I wish to receive a Cottonwood Circle Plaque (new members) Recognition: You will be listed as noted on pledge form above unless otherwise specified:____________________________ Loyal Contributor o Do you consider yourself a Loyal Contributor? Signature:__________________________Date:____________ (required) o I would prefer to remain anonymous. Thank You for investing in your community! WHITE COPY - PAYROLL YELLOW COPY - UNITED WAY PINK COPY - DONOR DID YOU KNOW: When you give to United Way of Campbell County, 99% of your contribution stays here in Campbell County. In 2013, over 17,000 people were served by the agencies and programs assisted by United Way of Campbell County. During the 6th Day of Action, Campbell County residents help collect over $5,000 worth of peanut butter, diapers and toothbrushes and toothpaste for United Way of Campbell County’s partner agencies. United Way of Campbell County www.unitedwaycampbellcounty.org No goods or services were given in exchange for this contribution. The entire contribution is tax deductible as allowed by law. If a single payment of $250 or more is made, United Way will issue a receipt for tax purposes. If a pledge is made by payroll deduction, donor must keep pink copy of pledge form for tax purposes, and may request a separate tax receipt. Donor information is kept strictly confidential unless you authorize us otherwise.
© Copyright 2018 AnyForm