United Way pledge form 2017

2017 UNITED WAY COMMUNITY CAMPAIGN

30 Laurel Street, Hartford, CT 06106 | 860.493.6800 | UnitedWayInc.Org Please complete and return to your company or mail to the address above.

1

PLEASE PROVIDE INFORMATION IN THE SPACE BELOW: MR/MRS/MS/DR

FIRST NAME

MI

LAST NAME

BIRTH DATE (MM/YYYY)

HOME ADDRESS (For credit card charges and bill me options, your billing address is required.) CITY/STATE/ZIP COMPANY PERSONAL EMAIL

HOME PHONE

2

WORK PHONE

COMPANY LOCATION

EMPLOYEE ID NUMBER

WORK EMAIL

MOBILE PHONE

PLEASE CHOOSE TOTAL GIFT AMOUNT AND METHOD OF GIVING

PREFERRED FORM OF CONTACT

MY TOTAL ANNUAL GIFT = $

PAYROLL DEDUCTION

I authorize my employer to deduct my total annual gift from my paycheck in equal amounts. I will contribute $ I receive my paycheck:

CREDIT CARD

WEEKLY (52/YEAR)

EVERY TWO WEEKS (26/YEAR)

BILL ME

VISA

ONE TIME

$

PROCESSED UPON RECEIPT BY UNITED WAY

MONTHLY

$

PER MONTH (STARTING MARCH 2018)

QUARTERLY $

CHECK

PER QUARTER (STARTING MARCH 2018)

OR

SEMI-MONTHLY (24/YEAR)

BILL ME BY EMAIL

Home address and email required above.

per pay period.

MONTHLY

MC

AMEX

DISCOVER

CREDIT CARD NUMBER

EXP DATE

NAME ON CARD

PHONE

CASH

Enclosed is my check payable to the United Way Campaign TOTAL $

SECURITIES: PLEASE CALL UNITED WAY TO TRANSFER FUNDS AT 860.493.6800

CHECK #

My leadership gift or combined household gift of $1000 or more qualifies me for membership in the Constitution Society.

Spouse/Partner gift AMOUNT $ Spouse/Partner name: Employer: Please list my/our name(s) as follows: I have been a loyal contributor to the United Way Campaign since (yyyy):

3

I/We prefer our leadership gift to remain anonymous

I CHOOSE TO IMPROVE LIVES IN THIS WAY:

YES, I WANT TO FIND THE BEST WAY

by making the biggest impact locally and support all four United Way priority areas.

AMOUNT $

OR

I CHOOSE TO TARGET MY GIFT TO ONE OR MORE OF THE FOLLOWING PRIORITY AREAS: EDUCATION Ensure that children are on track to graduate high school college and career ready

AMOUNT $

FINANCIAL SECURITY Help families get on the pathway to a financially secure future

AMOUNT $

BASIC NEEDS Ensure that there are services available in times of need

AMOUNT $

HEALTH Support healthier beginnings and healthier lives

UNITED WAY MEMBERSHIP OPPORTUNITIES I would like to JOIN/RENEW the following membership(s):

4

AMOUNT $

I want my contributions to benefit all United Way partners with the exception of

UNITED WAY WOMEN’S LEADERSHIP COUNCIL (An additional gift of $250, $500 or $1000 qualifies you for membership.)

AMOUNT $

UNITED WAY EMERGING LEADERS SOCIETY (A gift of $50 or more to United Way qualifies you for membership.)

AMOUNT $

YOUR SIGNATURE

X

YOUR SIGNATURE IS REQUIRED FOR PAYMENT

DATE

OPTIONAL DIRECTED GIFT

AMOUNT $

Direct your gift to another qualified not-for-profit organization.

Organization Name, Address, phone number. Please see reverse for more details.

AMOUNT $

Neighborhood Arts and Heritage Diversity through arts and culture programs in Greater Hartford Please check here if you want to be acknowledged by the organization to which you have directed a gift.

For Campaign use only

White Copy: United Way

Yellow Copy: Company

Pink Copy: Employee

0717/40K

THANK YOU FOR YOUR GIFT!

No goods or services were provided in exchange for this contribution.

LEARN MORE AND GET INVOLVED! Call us at 860.493.6800 or visit UnitedWayInc.Org Facebook.com/UnitedWayInc

@UnitedWayInc

@UnitedWayInc

ABOUT YOUR GIFT Please keep a copy of this form for your tax records. You will also need a copy of your paystub, W-2 or other employer document showing the amount withheld and paid to a charitable organization. Consult your tax advisor for more information.

Please note that such designated gifts will be distributed through United Way.

OPTIONAL DIRECTED GIFTS United Way of Central and Northeastern Connecticut is honored to partner with your employer in helping employees give back to issues they care about. If you direct a portion or all of your gift to any qualified not-for-profit organization recognized as a 501(c)(3) by the Internal Revenue Service, the organization’s name, address and phone number is required.

If we cannot locate your directed organization, or if it is not an IRS qualified 501(c)(3) organization that is Patriot Act Compliant, we will make every reasonable attempt to contact you. If we cannot contact you, your gift will go to United Way of Central and Northeastern Connecticut. Please note that such designated gifts are not monitored by United Way of Central and Northeastern Connecticut.

HOW YOUR CONTRIBUTIONS ARE DISTRIBUTED Contributions directed to organizations through United Way are subject to a 10 percent fee (includes administration and fundraising costs), capped at $100 per directed gift (assessed on a pro-rata basis upon gift proceeds received).

Payroll deduction contributions will be distributed directly to designated organizations in April, July, October, and December 2018, and March and June 2019, if proceeds and pledge details are received by United Way on or before the end of the month preceding payout.

Check, credit card or stock payments will be distributed to directed organizations by February 28, 2018, if proceeds and pledge details are received by United Way on or before December 31, 2017.