Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Payroll Deductions Options *

Donation Per Pay Period

$25

$20

$10

$5

$2

My Fair Share – 1 hr’s pay per month

Every Day Hero - $1 per day - $365 per year

merging Leader - $10/week - $520 per year

Leadership Giving, Red Feather Society - $83.33 per month ($1,000)

1% - approx. 2 hrs pay per month

2% - approx. 4 hrs pay per month

Other

Payment Options *

12 pay periods

24 pay periods

26 pay periods

52 pay periods

1 time payroll deduction

Other- option not listed

Leadership Giving

Red Feather Society - $1,000 – 1,999 ($83.33 per month) Silver Feather Society - $2,000 – 3,499 Gold Feather Society - $3,500 – 4,999 Builders Society - $5,000 – 9,999 Alexis de Tocqueville Society - $10,000+

I wish to remain anonymous

I would like more information on United Way's Planned Giving

Spouse/Significant Other Name

First Name

Last Name

Loyal Contributor Information *

Have you given to United Way (in any community) for 10 or more years?

Yes

No