You must have JavaScript enabled to use this form. 1 Start 2 Complete Name Employer Street Address City State ZIP Phone Birthdate Email Payroll Deduction Pay periods/year 52 Weekly 12 Monthly 26 Bi-Weekly 24 Twice Monthly Up to $19,999: 1 hour’s pay per month $20,000-$49,999: 1% $50,000-$99,999: 2% $100,000 and up: 3% Bill me Bill Me ($100 minimum total pledge) Pay Now In Full Pay Now In Full (Please Mail Check to Address below) Check Combine My Gift with Spouse/Partner Combine My Gift with Spouse/Partner Spouse/Partner Name Spouse/Partner Employer BE A LEADERSHIP DONOR Builders Society ($500-$999) $9.12-$19.23 $19.24-$38.46 Red Feather Society ($1,000 - $1,999) $19.24-$38.46 $38.47-$76.92 Silver Feather Society ($2,000 - $3,499) $38.47-$67.30 $76.93-$134.61 Gold Feather Society ($3,500 - $4,999) $67.31-$96.15 $134.62-$192.30 Platinum Feather Society ($5,000 - $9,999) $96.16-$192.30 $192.31-$384.61 Please check if you would like to remain anonymous Please check if you would like to remain anonymous Please print how you want your name to appear in recognition materials PLEASE SEND ME: Information on Young Professionals Board Information on Women United Information on Volunteer Opportunities CHECK IF YOU HAVE Included UWCC in your will or estate plan Given to UWCC for 25 years or more Retired or plan to retire within the next 12 months Designation United Way asks you to leave your gift undesignated. This will allow local volunteers who have spent time studying the needs in our community to allocate the funds where desperately needed. However, if you wish to designate to a specific agency or other United Way, please indicate below.Thank you for your support! In accordance with IRS requirements, please keep a copy of your pledge card for your tax records. United Way of Cullman County has not provided any goods or services in consideration, in whole or in part, for this contribution. Information provided to United Way is used only to properly credit your contribution and communicate with you about United Way and related programs. United Way respects the privacy of our contributors and does not sell, trade, or rent your information. If you do NOT want your name released in printed materials or on our website, please check the “anonymous” box on this form. Submit
