MY TOTAL PLEDGE Your 2015 pledge will be distributed in 2016.
□ Payroll Deducon: I authorize the Comptroller to deduct $_____________
per month beginning January 2016.
Last four digits of SS# required for payroll deducon.
□ Cash □ Check Check #_______ Check Date__________
(Payable to Hawaiʻi Island United Way)
□ Bill Me □ One Time □ Monthly □ Quarterly (Secon 1 must be completed)
□ Credit Card:
I authorize a
□ One Time □ Monthly □ Quarterly charge to my credit card.
(Secon 1 must be completed)
Account #___________________________ Exp. Date_________ CVV_______
□ Automac Transfer:
I authorize my financial instuon to transfer $_______ monthly from my
checking account to HIUW beginning _______ /_______2016.
(Aach a voided check.)
MONTH DAY
Hawai‘i Island United Way
2015 STATE EMPLOYEE PLEDGE FORM
When you give to the Hawai‘i Island United Way,
your donaon stays right here on Hawai‘i Island
to help our local ‘ohana. Mahalo nui loa!
MY INFORMATION All informaon must be complete. (Please type or print clearly.)
□ Mr. □ Mrs. □ Other________ □ Suffix_______ SS# XXX-XX-____ ____ ____ ____ PR-DIST NO.____________________
NAME
(Last, First, Middle Inial) ________________________________________________ Job Title __________________ AGT 001
Home/Billing Address_________________________________________________ City/State___________________ Zip________
Day Phone_______________________ Email Address______________________________________________________________
P.O. Box 745 Hilo, Hawaiʻi 96721 • (808) 935-6393 • www.hiuw.org
OPTIONAL I would like to designate to the following Agency/Program.
Specific HIUW Partner Agency/Program
1________________________ $_______
2________________________ $_______
3________________________ $_______
Specific Community Iniave
Educaon $_______
Income $_______
Health $_______
A 501 ( c ) (3) Non-Profit Agency
(Minimum $50 donaon. Admin fee applies.)
1________________________ $_______
2________________________ $_______
3________________________ $_______
SIGN HERE Original Signature Required. NO PHOTOCOPIES OF SIGNATURE ACCEPTED.
______________________________________________
SIGNATURE REQUIRED
HIUW—Original • DONOR—Please make a copy for your records.
□ Please withhold my name from publicaon.
□ Yes! Please email me updates.
□ Yes! Please send me Planned Giving informaon.
□ Yes! I would like to volunteer with HIUW.
Total Annual
Payroll Deducon
$_________________
Cash/Check
$_________________
Total Bill Me
$_________________
Total Credit Card
$_________________
Total Auto Transfer
$_________________
MY TOTAL PLEDGE
$__________
PAYROLL DEDUCTION
GIVING GUIDE
DOLLARS 12
PER MONTH
MONTHS
$5 $60
$10 $120
$20 $240
$50 $600
$100 $1,200
$250 $3,000
Giving is a personal
decision and is
voluntary. Payroll
deducon is a
convenient way to give.
Whatever amount you
choose to give,
mahalo nui loa.
Your gi changes lives
and makes a difference!
click to sign
signature
click to edit
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