United Way of Greater Rochester · 75 College Avenue · Rochester, NY 14607-1009 · uwrochester.org · Call (585) 242-6512 or e-mail firstname.lastname@example.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
Mr./Mrs./Ms./Dr. First name M.I. Last name
Work Date of birth (MM/DD/YYYY)
Employer (or former employer if retired)
Please combine my gift with my spouse’s/partner’s gift.
Spouse’s/partner’s employer (if applicable)
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.
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. $
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
My Impact (optional)
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
Labor Leaders Club
Emerging Leaders Society ($500 or more for ages
40 and under)
Tocqueville Society ($10,000 or more)
Join Leaders United (optional)
TOTAL GIFT AMOUNT: $
How much would you like to deduct per pay period?
How often are you paid per year?
Other ( pay periods)
DIRECT GIFT (Gifts of $25 or less will be billed/charged one time.)
Check (made payable to United Way)
Date to charge/bill:
Upon receipt by United Way
Billing start date:
Please contact Kay Hall at email@example.com or (585) 242-6535
for other payment options.
My Signature (required)
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.