2016 RCUH EMPLOYEE PLEDGE FORM
MAHALO for making a difference in our community!
“LIVE UNITED”
Input By: _______________Edit by: _________________
Input Date: ______________ Edit Date: _______________
INSTRUCTIONS: Complete # 1 – 8
1. PRINT NAME: (Last, First, Middle Initial)
3. *SSN (Last 4-digits required for payroll deduction):
4. UNITED WAY ORGANIZATIONS: (check one) Select the United Way Program you would like to contribute to.
NOTE: You may contribute to multiple United Way Programs by completing separate forms for each program. Original Donation Forms
are required for each United Way organization.
Aloha United Way (Oahu) Hawaii Island United Way Maui United Way Kauai United Way
(AUW) (HIUW) (MUW) (KUW)
5. SELECT A METHOD OF CONTRIBUTION: (Your 2016 contribution will be distributed in 2017)
A. PAYROLL DEDUCTION (*Last 4-digits of Social Security Number Required)
I authorize RCUH to deduct $ ______________ per pay period beginning December 16, 2016.
5A. Total Payroll Deduction per year
(24 per pay periods in a year)
$ ______________
B. CASH OR CHECK (Payable to the specific united way selected above in Section 4)
5B. Total Cash or Check Amount
$ ______________
C. VISA MASTERCARD AMERICAN EXPRESS (Minimum $25.00 charge)
I authorize a one time charge to my credit card #______________________________________________
card expiration date ___________ /___________ (Charge is processed upon receipt of this form)
(month) / (year)
5C. Total VISA, M/C or AMEX Amount
$ ______________
D. AUTOMATIC TRANSFER (attach a voided check)
I authorize my financial institution to transfer (monthly) from my checking account ___________________,
to the United Way Organization I selected above in Section 4. Beginning _____________15, 2017 or on the
next business day. (month)
5D. Total Automatic Transfer Amount
$ ______________
E. BILL ME $ _________ Monthly Beginning ____/_____ Quarterly Beginning ____/____
One time ____/_____ (date) (date)
(date) (Minimum total Bill Me Pledge $48.00)
5E. Total Billing Amount per year
$ ______________
6. CALCULATE: Total Sum of your Donation(s) in SECTION 5. (5A + 5B + 5C + 5D + 5E)
7. YOUR SIGNATURE & ADDRESS
By signing this form, I understand that this is a voluntary pledge and my contributions will be distributed to the United Way agency as indicated
above in Section 4. My deduction period is from December 16, 2016 to December 15, 2017. No goods or services of more than nominal value
have been given in return for this contribution.
SIGNATURE: ________________________________________________ DAYTIME PHONE: (______) ______________________
ADDRESS: _____________________________________________CITY:________________________ ZIP CODE: ______________
8. THIS IS THE OFFICIAL RCUH UNITED WAY PLEDGE FORM. PLEASE MAKE A COPY FOR YOUR FILE AND SEND THE
ORIGINAL TO: RCUH Human Resources • Burns Hall, 4
th
Floor • 1601 East West Road • Honolulu, HI 96848
MAHALO FOR YOUR SUPPORT!!
FOR MORE INFORMATION CONTACT:
Aloha United Way (808-536-1951), Maui United Way (808-244-8787), Kauai United Way (808-245-2043),
Hawaii Island United Way (808-935-6393), or RCUH Human Resources (808-956-6979)
DEADLINE: November 4, 2016
click to sign
signature
click to edit
![]()
