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30 Laurel Street, Hartford, CT 06106

UNITED WAY CAMPAIGN

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CONNECT WITH US:

unitedwayinc.org facebook.com/unitedwayinc @unitedwayinc

LAST NAME

HOME PHONE

HOME ADDRESS (For credit card charges and bill me options, your billing address is required.)

CITY

STATE

COMPANY NAME

EMPLOYEE ID NUMBER

DAYTIME PHONE

PERSONAL E-MAIL ADDRESS

MOBILE PHONE

PREFERRED FORM OF CONTACT

MR/MRS/MS/DR

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FIRST NAME

MI

ZIP

THANK YOU FOR INVESTING IN OUR COMMUNITY THROUGH UNITED WAY. TO SELECT ONE OR MORE INTEREST AREAS, CHECK BELOW. See reverse for an explanations of the interest areas.

AMOUNT $

EDUCATION Children succeed academically and in life.

AMOUNT $

FINANCIAL SECURITY Families become financially secure. HEALTH Individuals are healthier.

AMOUNT $

BASIC NEEDS Everyone has food, shelter and other essential services.

AMOUNT $

UNITED WAY COMMUNITY INVESTMENT To support all of the above interest areas, check here.

AMOUNT $

By investing in our community through United Way, you improve lives and create measurable, lasting change for all of us. I want my contribution to benefit all United Way partner agencies with the expectation of:

AMOUNT $

— Improving the lives of people affected by disability or chronic disease.

AMOUNT $

NEIGHBORHOOD ARTS AND HERITAGE — Diversity through arts and culture programs in Greater Hartford. DIRECT YOUR CONTRIBUTION TO AN AGENCY OF YOUR CHOICE:

AMOUNT $ Agency Name

Agency address and phone number. Please see reverse for more details.* PLEASE CHECK HERE IF YOU WANT TO BE ACKNOWLEDGED BY THE AGENCY YOU HAVE DESIGNATED.

UNITED WAY LEADERSHIP GIVING

UNITED WAY MEMBERSHIP OPPORTUNITIES

I have been a loyal contributor to the United Way Campaign since

I would like to JOIN/RENEW the following membership:

. (yyyy)

My leadership gift or combined household gift of $1,000 or more qualifies me for membership in the Constitution Society.

United Way Women’s Leadership Council. For an additional gift of:

Spouse/Partner gift amount:

Contributions support the Council’s work for families in our community.

$250

Spouse/Partner name:

to United Way, through workplace or individual giving, qualifies membership.

Please list my/our name(s) as follows: I/We prefer our leadership gift to remain anonymous.

PLEASE SELECT YOUR METHOD OF INVESTING

PAYROLL DEDUCTION

I WILL CONTRIBUTE $

$1,000

United Way Emerging Leaders Society. A contribution of $50 or more directed

Employer:

3

$500

CHECK PER PAY PERIOD

THANK YOU FOR LIVING UNITED!

TOTAL GIFT $

HOME ADDRESS REQUIRED FOR THESE PAYMENT OPTIONS

CASH

CREDIT CARD

BILL ME

o One time $ ______________ processed upon receipt by United Way

I receive my paycheck:

Enclosed is my check payable to the United Way Campaign.

o Weekly (52/year)

$ TOTAL

o Quarterly $ ______________ per quarter (starting March 2015)

o Every Two Weeks

CHECK #

o VISA

o Semi-Monthly (24/year)

o SECURITIES

o Monthly

Please call United Way to transfer funds at (860) 493-6800. $ (Approx. value)

I authorize my employer to deduct my total annual contribution from my paycheck in equal amounts.

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SIGNATURE (REQUIRED)

FRID ID # _________________ (for Campaign use only)

o Monthly

$ ______________ per month (starting March 2015) o MC

o AMEX

o Discover

CREDIT CARD NUMBER 

EXP. DATE

NAME ON CARD

PHONE #

DATE

White Copy - United Way

Yellow Copy - Company

Pink Copy - Employee

x493

0514-55K


What is United Way Community Investment?

*OPTIONAL DESIGNATED GIFTS Thank you for your contribution to the 2014 United Way Campaign. United Way of Central and Northeastern Connecticut is honored to partner with your employer in helping employees give back to issues they care about. You may designate 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. You must include the agency’s name, address and phone number. If you selected an agency to receive your contribution, we will verify that it is U.S. Patriot Act compliant and certified by the Internal Revenue Service as a 501(c)(3) or other tax-exempt organization. If we cannot locate your designated agency, 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. Please note that such restricted gifts are not monitored by United Way of Central and Northeastern Connecticut or Community Health Charities of New England. For a list of local United Way and Community Health Charities of New England partner agencies, please visit unitedwayinc.org/partners.

HOW YOUR CONTRIBUTIONS ARE DISTRIBUTED CONTRIBUTIONS DESIGNATED TO AGENCIES through United Way are subject to a 10 percent fee (includes administration and fundraising costs), capped at $100 per designated gift (assessed on a pro-rata basis upon gift proceeds received). No fees are deducted by United Way from contributions to Community Health Charities of New England, or any Community Health Charities Federation or their member charities. Community Health Charities of New England deducts its own administrative fee prior to disbursement of these gifts. PAYROLL DEDUCTION CONTRIBUTIONS will be distributed directly to designated agencies in April, July, October, and December 2015, and March and June 2016, 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 designated agencies by February 28, 2015, if proceeds and pledge details are received by United Way on or before December 31, 2014. UNDESIGNATED CAMPAIGN PLEDGES will be distributed through United Way and Community Health Charities of New England as agreed upon by both organizations.

THANK YOU FOR YOUR CONTRIBUTION! If you selected United Way Community Investment or related interest areas (education, financial security, health, basic needs) as your investment of choice, thank you. You are helping create measurable, lasting change in the lives of local children and families. 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 paystub, W-2 or other employer document showing the amount withheld and paid to a charitable organization. Consult your tax advisor for more information.

United Way of Central and Northeastern Connecticut

30 Laurel Street

Hartford, CT 06106

unitedwayinc.org


UW Campaign 2014 Pledge Form