Kauai 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 Kauai United Way.)
*
Credit Card: I authorize a one-time charge of $_____________ to be processed upon receipt of this pledge.
Visa MasterCard Card # ___ ___ ___ ___ – ___ ___ ___ ___ – ___ ___ ___ ___ – ___ ___ ___ ___
Exp. Date_____________
*
Bill Me: $_____________ (Minimum of $20.00) per month per quarter
one time on _____ /_____
month / year
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________________________________________________________
SIGNATURE REQUIRED
(No goods or services of more than nominal value given in return for this contribution.)
P. O. Box 1087 • Lihue, Hawaii 96766 • (808) 245-2043
KUW – 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.
NAME (Last, First, Middle Initial): ____________________________________________________________________________ AGT: 004
Home Address: __________________________________________________________________________________________________
City/State: _______________________________________________________________________________ Zip: _________________
Day Phone: __________________________________ E-mail Address: ___________________________________________________
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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!
MAHALO FOR YOUR GIFT.
Kauai United Way is our island’s umbrella charitable organization. One contribution
helps our whole island. Money raised on Kauai stays on Kauai. Kauai United Way’s
Participating Agencies offer a diverse array of dozens of social service programs that
save lives daily and help tens of thousands of Kauai people every year. When those
in need in our community get the professional help they deserve, every one of us
is better off. Let’s all live united - the Kauai United Way! For more information, visit
kauaiunitedway.org or call 245-2043.
Dollars per month 12 Payments
$5 $60
$10 $120
$20 $240
$50 $600
$100 $1,200
$250 $3,000
$500 $6,000
MY INFORMATION ~ All information must be complete. (Please type or print clearly.)
Mr. Ms. Other _______ Sufx _______ SS# _____________________ PR-DIST. NO.: _____________________
XXX-XX-
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