Pledge Form - United Way

My Information:

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone

Current Employer*

My Pledge Information

I would like to donate out of my paycheck.

Payroll contribution - DO NOT PUT $ SYMBOL, ONLY NUMBERS

I want to donate this amount out of each paycheck. ONLY PUT IN NUMERICAL AMOUNT. NO $ SYMBOL.

My pay period is:*

If you are a City of Younstown Employee, please mark that option not your actual pay period.

My yearly total:

Multiply the contribution per pay period by the number of pay periods to get your total gift. For example: $50 per pay period for 52 pay periods is $2,600 for the total gift.

Authorization*

I authorize for my employer to deduct this amount from my paycheck.

By checking this box, it serves as an authorization that this is the pledge you would like to make through payroll deduction. This serves the same as your signature on a paper copy of the pledge form.

Designate part of my gift

I can designate up to half of my gift of $100 or more to a 501c3 non-profit or 100% of my gift to another United Way. I must indicate where I want my gift to go.

Amount of designation

Bill Me:

I would rather be billed than give out of my pay check. Please fill out this section if you do not want to give out of your paycheck, but would like to be billed and pay by check or credit card.

Total Pledge - DO NOT PUT $ SYMBOL, ONLY NUMBERS

This is the amount I would like to pledge. Please bill me. DO NOT PUT $ SYMBOL, ONLY NUMBERS.

Bill Me:

If you would rather the United Way of Youngstown and the Mahoning Valley bill you for your pledge instead of it coming out of your pay check, please fill out this section by marking how you would like that to occur.

Authorization*

I authorize you to bill me for this amount.

By checking this box, it serves as an authorization that this is the pledge you would like to make, either through your credit card or through the bill me option. This serves the same as your signature on a paper copy of the pledge form. Once you click the option for Credit Card please input your card information.

Leadership Club

If you donate $1,000 or more please answer these questions.

Leadership Recognition*

Please indicate how you want to be listed in our Annual Report

Leadership Recognition*

Please list my name in the Annual Report as listed below: