UNITED WAY
PLEDGE FORM
GREAT THINGS HAPPEN
WHEN WE LIVE UNITED
MY CONTACT INFORMATION
PLEASE PRINT LEGIBLY. (*required)
DR. / MR. / MS. / MRS. FIRST, MIDDLE INITIAL & LAST NAME*____________________________________________________
(circle one)
HOME ADDRESS*______________________________ GENDER (circle one) FEMALE MALE
CITY/STATE/ZIP*_______________________________ EMPLOYER__________________________________________
HOME PHONE________________________________ EMPLOYEE ID________________________________________
CELL PHONE_________________________________ WORK PHONE________________________________________
PERSONAL EMAIL______________________________ WORK EMAIL________________________________________
MY UNITED WAY INVESTMENT
MY TOTAL PLEDGE AMOUNT IS
mEASY PAYROLL DEDUCTION
A. Select your payroll frequency:
m Weekly (52) m Bi-weekly (26)
m Semi-monthly (24) m Monthly (12)
B. Amount per pay period:
m $10 m $25
m $50 m $100
m Other ______
C. Total Annual Gift Amount
(AxB)= $______________
Please select payroll deduction or other payment option.
mPAY BY CHECK or CASH
Attach your check made out to: United Way of Forsyth County. Total Annual Gift Amount $_____________
mDIRECT BILL (complete A – D) Minimum donation of $100 or more. Home address is required.
A. Select one: mMonthly (12) mQuarterly (4) mSemi-annually (2) mOnce (1)
B. Installment Contribution $_____________ C. Billing Start Date___________
D. Total Annual Gift Amount (AxB) = $______________
mCREDIT CARD (complete A – E) Minimum donation of $100. Also available at forsythunitedway.org
mSINGLE PAYROLL DEDUCTION
A. Card #_______________________________________Exp. Date___________
B. Select one: mMonthly (12) mQuarterly (4) mSemi-annually (2) mOnce (1)
C. Installment Contribution $_____________ D. Billing Start Date___________
E. Total Annual Gift Amount (BxC) = $______________
(Total Annual Gift Amount) mStocks or Securities Transfer For assistance, please call United Way at 336-723-3601.
$______________on__________
RECOGNITION &
LEADERSHIP GIVING
METHOD OF PAYMENT
$
(Date)
SELECT AND COMPLETE ALL THAT APPLY.
m I am a Loyal Contributor. I have been investing in my community with United Way since_________.
m My contribution is part of a household gift. Combine my pledge with my spouse/partner:
Spouse/Partner Name_______________________________Employer____________________________________
m Please list my/our name(s) as follows in publications______________________________________________________
m I prefer that my/our gift remain anonymous.
LEADERSHIP GIVING Select all that apply. Please see reverse of form for step-up programs and information on leadership giving contribution requirements.
m Tocqueville Leadership Society
($10,000+ contribution)
m Leadership Circle
($1,000+ contribution)
m Women’s Leadership Council
($1,000+ contribution)
My Signature
m Young Leaders United
(ages 18-40, $250+ contribution)
Date
(Signature and date are both required for all methods of payment)
THANK YOU FOR INVESTING IN YOUR COMMUNITY
No goods or services were provided in exchange for this contribution. Please keep a copy of this form for your tax records. You will also need a copy of your pay stub, W-2 or other employer document showing the amount withheld
and paid to a charitable organization. Consult your tax advisor for more information. A copy of this organization’s solicitation license is available from the state at 1-800-830-4989. This license is not an endorsement by the state.
CARING SHARE GUIDE
STRENGTHENING OUR COMMUNITY THROUGH
EDUCATION, FINANCIAL STABILITY & HEALTH
UNITED WAY’S CARING SHARE GUIDE IS INTENDED TO HELP YOU DETERMINE HOW MUCH TO GIVE.
Annual Caring WeeklyAnnualAnnual Caring WeeklyAnnual
Income ShareContribution Gift Income ShareContribution Gift
Up to $19,999
0.7%
Up to $2.69
Up to $140 $60,000-$74,999
1.7%
$19.62-$24.52 $1,020-$1,275
$20,000-$39,999
1.0%
$3.85-$7.69 $200-$399 $75,000-$99,999 2.0% $28.85-$38.44$1,500-$1,999
$40,000-$59,999
1.4%
$10.77-$16.15 $560-$840 $100,000 & Up
2.5%
$48.08 & Up $2,500 & Up
LEADERSHIP GIVING. MAXIMIZE YOUR IMPACT.
LEADERSHIP GIVING
We are 6500 strong. We come from different places with different backgrounds, but together we LIVE UNITED.
Join a leadership group that’s right for you!
LEADERSHIP CIRCLE ($1,000 or more)
Members of LC are bold, inspired, and connected to play a critical role in addressing our community’s most pressing needs.
They recognize the power of individuals to make lasting change around education, health, and financial outcomes in our community.
Want more info? [email protected] | 336.721.3601
TOCQUEVILLE LEADERSHIP SOCIETY ($10,000 or more) Step up programs available
For over 30 years, the Tocqueville Society has demonstrated what collective community leadership can accomplish. An elite group of local philanthropists,
society members connect with like-minded pioneers investing in generations to come. Participate in a step up program by incrementally increasing your gift
over three years while enjoying membership benefits right away. Want more info? [email protected] | 336.721.3601
WOMEN’S LEADERSHIP COUNCIL ($1,000 or more) Step up programs available
Members of WLC strive to educate, engage, and empower women as philanthropic leaders. The council is focused on accelerating progress toward United Way’s
bold goal of reaching 90% graduation rate by 2018. Participate in a step up program by incrementally increasing a gift of $500 by $100 annually while enjoying
membership benefits right away. Want more info? [email protected] | 336.721.3601
YOUNG LEADERS UNITED ($250)
Open to those 40 and under, Young Leaders United harnesses the energy of young professionals who desire to impact lives and create a better community
for all. Benefits: leadership development, access to senior leadership, social networking, hands-on ways to make a difference.
Want more info? [email protected] | 336.721.3601
Optional :
m Please designate $_________of my gift to the following organization (minimum $100):
Agency Name_______________________________________
County (If outside of Forsyth County) _________________________
Designated organizations must be a tax-exempt 501(c)3 health and human services agency. If the designated organization is not a certified 501(c)3 health and human services agency, if the
designation minimum is not met, if the organization name is not legible, or if all appropriate forms have not been submitted by the designated organization, United Way of Forsyth County
reserves the right to redirect your gift to the general fund. Payroll designations are assessed an uncollectible percentage and designations to agencies are assessed a fundraising and
administrative fee in accordance with United Way Worldwide Membership Standards. For more information, please call (336)723-3601or visit forsythunitedway.org
STAY CONNECTED
ForsythUnitedWay.org
UWForsyth
United Way of Forsyth County • 301 N. Main St., Suite 1700, Winston-Salem, NC 27101 • 336-723-3601