Please do not mail this envelope. Call (860) 493-6800 for pick-up. Company ID #
For Campaign Use Only:
Envelope #
Initials
UNITED WAY CAMPAIGN
Partial Report Full Report Retiree Report eWay Report
REPORT ENVELOPE CAMPAIGN YEAR:
Organization Name Street Address City
# of employees in organization:
State
# of contributors giving $1,000 or more in this envelope:
Zip
STEP 1: GIFT INFORMATION
* Please use Special Event Report Envelope for event funds.*
CONTRIBUTIONS/PLEDGES
# OF GIVERS
TOTAL AMOUNT
AMOUNT ENCLOSED
Payroll Deductions
(Employer retains signed yellow forms. Please enclose white forms) *
OTHER PLEDGE METHODS Check/Cash (Please enclose white forms and checks payable to United Way Campaign.)*
Credit Card
(Please enclose signed white forms with addresses)*
Billed by United Way
(Please enclose signed white forms with addresses)*
Stock
(Please enclose signed white forms with addresses)*
Memo Bypass
(For United Way use only)
SUBTOTAL Corporate Pledge GRAND TOTAL FOR ENVELOPE
STEP 2: CAMPAIGN COORDINATOR INFORMATION Name
Signature
Date
Phone
STEP 3: BILLING INFORMATION, IF APPLICABLE Billing Address
Phone
Contact for company billing questions
(Campaign Use Only)
Donor Relations: Staff/LE Name: __________________________________________ Date: __________________________________________________ United eWay Campaign Use Only: Uploaded By/Date________________________________________ Special Gifts
Third Party
Donor Services: Credit Date: _________ Deposit Date: _________ Deposit ID#: _________ Audited By: _______________________________ Date: _______________ Processed By: _____________________________ Date: _______________ Date Posted: ___________________________________________________ Batch Control Number
THANK YOU! United Way Campaign • 30 Laurel Street • Hartford, CT 06106-1374 • (860) 493-6800 • FAX (860) 493-6859 • unitedwayinc.org