Fillable Form 2: Pledge Form TOTAL GIFT AMOUNT: $

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Form 2: Pledge Form TOTAL GIFT AMOUNT: $

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United Way of Greater Rochester · 75 College Avenue · Rochester, NY 14607-1009 · uwrochester.org · Call (585) 242-6512 or e-mail contactus@uwrochester.org with questions
Please make a copy or take a photo of your completed form for your records.
My Information (Please print.) My Gift (Please choose payroll deduction or direct gift.)
If not preprinted above, please be sure to fill in your name and/or address in the fields below so that United Way can
properly account for and acknowledge your gift. United Way does not rent, trade or sell our lists of contributors.
United Way of Greater Rochester
Pledge Form
Mr./Mrs./Ms./Dr. First name M.I. Last name
Address
City/State/Zip
Phone:
Home
Cell
Work Date of birth (MM/DD/YYYY)
Preferred email
Employer (or former employer if retired)
Please combine my gift with my spouse’s/partner’s gift.
Spouse’s/partner’s name
Spouse’s/partner’s employer (if applicable)
1
ANOTHER OPTION FOR GIVING Please consider giving to United Way’s Community Impact
Fund to make the greatest impact for local people and our entire community. If you would like
to direct all or a portion of your gift to a donor options organization, you may do so below.
Donor options information can be found at uwrochester.org/donoroptions.
$
to this organization: ID#
$ to this organization: ID#
Please do not release my information to the organization(s) to which I designated.
( The sum of your donations in this section should equal your total gift amount in section 2.)
SUPPORT UNITED WAY’S COMMUNITY IMPACT FUND
Make the greatest impact by joining others to support the core building
blocks that help individuals, families and our community thrive.
HEALTH (3550)
Help families and individuals have their basic needs met, safe places to live, and social
and emotional connections to positively impact their quality of life. $
EDUCATION (3551)
Give kids the support they need to learn, grow and thrive. $
ECONOMIC MOBILITY (3552)
Provide access to tools and opportunities to help people increase income,
build wealth and improve financial stability. $
PLEASE USE MY GIFT TO SUPPORT ALL COMMUNITY IMPACT
FUND BUILDING BLOCKS
(3500) $
My Impact (optional)
3
2
When you contribute $1,000 or more ($500 for ages
40 and under) you are recognized as a Leaders United
member and will be invited to connect with other leadership
donors throughout the year. For more information about
United Way’s leadership giving networks please visit
uwrochester.org/leadership or see the back of this form.
YES, I WOULD LIKE TO JOIN LEADERS UNITED.
Please indicate if you would like to join one or more
of the following networks:

African American Leadership Society

Círculo Latino Leadership Society

Women United

Labor Leaders Club

Emerging Leaders Society ($500 or more for ages
40 and under)

Tocqueville Society ($10,000 or more)
Join Leaders United (optional)
4
TOTAL GIFT AMOUNT: $
PAYROLL DEDUCTION
How much would you like to deduct per pay period?
$
How often are you paid per year?
52x
26x
24x
20x
12x
Other ( pay periods)
DIRECT GIFT (Gifts of $25 or less will be billed/charged one time.)
Check (made payable to United Way)
Cash
Bill me:
One time
Quarterly
Monthly
Date to charge/bill:
Upon receipt by United Way
Billing start date:
Please contact Kay Hall at kay.hall@uwrochester.org or (585) 242-6535
for other payment options.
OR
Union Member
Retired
Signature Date
My Signature (required)
5
My name typed below serves as my signature and authorization for this pledge.
To make a payment via credit card, please visit uwrochester.org/give.
Thank you so much for your gift!
Please make sure your signature appears on the front page.
Authorizing a Regular Payroll Deduction
I understand that I am under no obligation to contribute to United Way of Greater Rochester. If I decide to contribute to United Way by authorizing deductions from my
pay to be forwarded to United Way, it is a decision I make voluntarily. I understand that the amount I authorize to be deducted will be subtracted from my pay for any pay
period in 2020-2021 in which my pay is large enough to cover the deduction. If there is a pay period in which my pay is insufficient to cover the United Way deduction
after all legally required deductions are made, my employer will not make a United Way deduction for that pay period. If a United Way deduction is missed for
any reason, it will not be made up on a later date without my express written direction. I understand that I may revoke my United Way deduction authorization
at any time by informing my employer in writing, and that my revocation will be effective within four pay periods or eight weeks, whichever is sooner.
Leadership Giving Networks
All individuals and couples who give $1,000 or more ($500 for ages 40 and under) will be recognized as Leaders United members and will be invited to connect with
other leadership donors, take part in events, volunteer activities, and more throughout the year. As a leadership giver, you may also choose to take part in any of the
networks below.
•
The African American Leadership Society recognizes the vital role African Americans play in improving the quality of life in Rochester.
•
Círculo Latino Leadership Society honors the influence and dedication of Rochester’s Latino community.
•
Women United empowers women of Rochester to make their unique voices heard.
•
The Labor Leaders Club recognizes philanthropy among organized labor in our community.
•
The Emerging Leaders Society recognizes and develops the spirit of philanthropy among our future leaders. The Emerging Leaders Society is open to individuals
and couples, ages 40 and under, who give
$
500 or more to United Way each year.
•
The Tocqueville Society comprises community leaders who make an annual gift of
$
10,000 or more to United Way, setting an extraordinary example of generosity for
others to follow. For more information about joining, please call (585) 242-6495.
•
United Way is one of Rochester’s largest and most efficient charitable means of supporting the planning, delivery and evaluation of local human service
programs. 92 cents of every contributed dollar is used to meet community needs.
•
All gifts are subject to a pledge loss reserve charge.
•
In accordance with the statement of Financial Accounting Standards 116, United Way will make every effort to forward your gift to the organization to which you
designate. However, if the organization is not in compliance with current United Way policy, or if this form is not completed as directed, United Way reserves the right
to redirect your gift to support United Way’s Community Impact Fund. For more information, please call (585) 242-6527.
•
United Way of Greater Rochester oversees the financial management of United Way of Genesee Country, United Way of Livingston County, United Way of Ontario
County, United Way of Wayne County and United Way of Wyoming County. Certain correspondence relating to these pledge forms will come from United Way of
Greater Rochester.
United Way does not provide goods or services in whole or partial consideration of any contributions made to United Way by payroll deduction. Upon request,
you may obtain a copy of United Way of Greater Rochester, Inc.’s latest financial report filed with the Attorney General by writing to United Way of Greater
Rochester, Inc., 75 College Avenue, Rochester, NY 14607 or from the New York State Attorney General’s office by calling 212-416-8401 or viewing their website
(www.charitiesnys.com). Registration with the New York State Attorney General Charities Bureau or any other government agency should not be construed as
an endorsement of United Way.
Gifts to United Way may be tax deductible. Please consult your tax advisor.
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Form 2: Pledge Form TOTAL GIFT AMOUNT: $

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Completed 4 May 2021

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