Workplace Pledge Card Your Name Title First Middle Last Suffix Your Contact Information Company Email Phone Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP Code Donation Method Preferred Donation Method Payroll Deduction Check Cash Bill Me Credit Card Payroll Deduction Contribution Amount Per Pay Period $5 $10 $20 $25 $50 Other… Please enter the NUMBER only $ Number of Pay Periods for Donation One Time 12 pay periods 24 pay periods 26 pay periods 52 pay periods Other… Please enter the NUMBER of pay periods for this donation Check Donation Amount of Check $ Make checks payable to United Way of Northwest Connecticut. Please give the check to your Campaign Coordinator within 24 hours of this pledge. Cash Donation Amount of Cash $ Please give your cash donation to your Campaign Coordinator within 24 hours of this pledge. Bill Me Details Frequency of Invoice One Time Quarterly Monthly Amount of EACH direct bill $ Credit Card Donation Select One One Time Donation Monthly Recurring Donation Amount of your One Time Donation $ Amount donated each month $ After completing this form you will be redirected to our payment page where you will be able to process your transaction in a secured environment. Please be sure to enter the same values that you have entered on this form. NOTE: A $4 credit card processing fee will be added to your donation. Total Annual Contribution TOTAL: $0 Update Donation Details Designation Options United Way Community Impact Fund Education Health Financial Stability Single Agency Mark all that apply I am a Loyal Contributor My gift, either alone or in combination with my spouse/partner, totals $1,000 or more. I would like to get involved with United Way’s governance I would like more information on the Young Professionals for United Way (for those who are 21 to 35 years old) I am interested in including United Way of Northwest Connecticut in my endowment and estate plans. Number of years contributing years 501(c)3 Organization Designation United Way will honor donor designation to United Way agency partners, any United Way and/or any 501(c) (3) entity. If your designated agency is not compliance with 501 (c)(3) status or the USA Patriot Act and other counter terrorism laws, United Way distribute the funds via the Community Impact Fund. A 10% processing fee in each designation will be deducted up to a maximum of $100. A minimum annual donation of $104 is required per agency, with a maximum of three designations. Restricted pledges below this amount will be distributed through the Community Impact Fund. Name of Organization Federal Tax ID # Street Address City State Zip Code Organization Phone Number Amount of Donation $ Check if you do NOT want us to release your name to the agency or receive a personal note. Agreement My signature below, confirms my pledge as stated above. Signature Reset (security question) What color is the sky? Proceed to Payment Page Submit Leave this field blank
