Maui United Way
MAHALO for making a difference in our community!
2015 STATE PLEDGE FORM
MY TOTAL PLEDGE $__________ AND HOW I CHOOSE TO PAY ~ Your 2015 pledge will be distributed in 2016.
Payroll Deduction: I authorize the Comptroller to deduct $ ___________ per month beginning January 2016 for a total
payroll deduction of $ _________. Last Four Digits Of SS# Required For Payroll Deduction.
Cash: $_________
Check: $_________ (Payable to Maui United Way.) Check #: _______________
*
Credit Card: I authorize a one-time charge of $_____________ to be processed upon receipt of this pledge.
Visa MasterCard AMEX Discover JCB (Billing address required for processing.)
Card # __________________________________________________ Exp. Date_____________
*
Bill Me: $_____________ (Minimum of $25.00 billed quarterly)
Designate my donation to:
(Minimum $25.00 per 501(c)(3) agency)
1. ________________________________________________ $ _______________
Agency Designation Name Amount
2. ________________________________________________ $ _______________
Agency Designation Name Amount
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________________________________________________________
SIGNATURE REQUIRED (No goods or services of more than nominal value given in return for this contribution.)
Mahalo for your support!
270 Hookahi Street, Suite 301 • Wailuku, Hawaii 96793 • (808) 244-8787
Original Signature Required.
NO PHOTOCOPIES OF SIGNATURES ACCEPTED.
Contact Maui United Way
at 244-8787 for additional forms.
www.mauiunitedway.org
MUW – Original • DONOR - Please make copies for your records.
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SIGN HERE
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MY TOTAL PLEDGE
$
* Section 1 must be completed.
Dollars per month 12 Payments
$5 $60
$10 $120
$20 $240
$50 $600
$100 $1,200
$250 $3,000
$500 $6,000
PAYROLL DEDUCTION GIVING GUIDE
Giving is a personal decision and is voluntary.
Payroll deduction is a convenient way to give.
Whatever amount you choose to give, mahalo
nui loa. Your gift changes lives and makes a
difference!
Please contact Maui United Way at 244-8787
for information, referrals, or to volunteer and
offer assistance.
NAME (Last, First, Middle Initial): ____________________________________________________________________________ AGT: 005
Home/Billing Address: ____________________________________________________________________________________________
City/State: _______________________________________________________________________________ Zip: _________________
Day Phone: __________________________________ E-mail Address: ___________________________________________________
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MY INFORMATION ~ All information must be complete. (Please type or print clearly.)
Mr. Ms. Mrs. Sufx _______ SS# _____________________ PR-DIST. NO.: _____________________
XXX-XX-
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