2015 Pledge Form My Personal Information My United Way

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.