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UNITED WAY CAMPAIGN

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30 Laurel Street, Hartford, CT 06106 unitedwayinc.org 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

MR/MRS/MS/DR

FIRST NAME

MI

ZIP

PERSONAL E-MAIL ADDRESS

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THANK YOU FOR INVESTING IN YOUR COMMUNITY. TO SELECT ONE OR MORE INTEREST AREAS, CHECK BELOW. See reverse for an explanation of the interest areas.

AMOUNT $

EDUCATION Helping children enter school ready to learn and succeed academically.

AMOUNT $

INCOME Assisting families to become financially secure. HEALTH Providing access to healthcare services.

AMOUNT $

BASIC NEEDS Ensuring everyone has food, shelter and other essential services.

AMOUNT $

UNITED WAY COMMUNITY INVESTMENT To support all of the above Community Investment interest areas, check here. United Way Community Investment advances the common good by improving lives and changing community conditions, contributing to a better life for all.

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 $

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.

LEADERSHIP GIVING

MEMBERSHIP OPPORTUNITIES

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

I would like to JOIN/RENEW the following membership:

. (yyyy)

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

My leadership gift or combined household gift of $1,000 or more qualifies me for membership

$250

in the Constitution Society. Spouse/Partner gift amount: Spouse/Partner name:

United Way Community Investment.

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 with a contribution of $50 or more to

Employer:

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$500

Contributions support the Council’s Family Financial Stability Initiative.

THANK YOU FOR LIVING UNITED! HOME ADDRESS REQUIRED FOR THESE PAYMENT OPTIONS

CHECK PER PAY PERIOD

TOTAL GIFT $

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 2014)

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 2014) 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

0613-65K


What is United Way Community Investment?

What is United Way Community Investment?

United Way Community Investment improves lives and changes local community conditions by focusing on: EDUCATION

INCOME

Helping children enter school ready to learn and succeed academically.

Assisting families to become financially secure.

• School readiness

• Adult literacy

• Academic achievement

• Financial education

• Youth leadership skills

• Improving access to income supports

• Parent education and support

• Training and job placement support

HEALTH

Providing access to healthcare services.

• Community Health Charities of New England • Prevention, treatment and research

BASIC NEEDS

Ensuring everyone has food, shelter and essential services.

• Information and referral • Food, clothing and shelter

• Home healthcare services

• Disaster prepardness and response

• Mental health services

• Intellectual disability services

To learn more and to get involved, please visit unitedwayinc.org

Questions? Please visit: unitedwayinc.org/FAQ or call 860-493-6800 GIVE.ADVOCATE.VOLUNTEER. *OPTIONAL DESIGNATED GIFTS 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 we cannot locate your designated agency, or if it is not an IRS qualified 501(c)(3) organization, we will make every reasonable attempt to contact you. Please note that such restricted gifts are not monitored by United Way or Community Health Charities of New England (CHCofNE). For a list of local United Way and CHCofNE 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 CHCofNE or any CHC Federation or their member charities. CHCofNE 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 2014, and March and June 2015, 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, 2014, if proceeds and pledge details are received by United Way on or before December 31, 2013.

UNDESIGNATED CAMPAIGN PLEDGES will be distributed through United Way and CHCofNE as agreed upon by both organizations.

THANK YOU FOR YOUR CONTRIBUTION! 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


United Way Campaign Pledge Form - 2013  
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