Oce Use Only: o MO o STO o TO o WO
o PAYROLL DEDUCTION $ x =
amount per pay period number of pay periods example, 52, 26 etc. total yearly contribution
o Check enclosed in the amount of $ [payable to United Way of Southeast Louisiana]
o Cash enclosed in the amount of $
o Bill Me o Monthly o Quarterly o Annually Start date __________________ Amount to bill $_______________________
o Stock Transfer - Please call 504-827-6841. No. of Shares ________________ Stock Name __________________________________________________________
o Credit/Debit Card in the amount of $ [$26 minimum donation. Please ask your coordinator for a confidential envelope.]
MY TOTAL CONTRIBUTION:
LEADERSHIP SOCIETY (List how you & your spouse/partner would like to be recognized if total combined gift is $500 or more.) o I prefer to remain anonymous.
o Women United [women who give financial resources
and time] Please select level of giving below.
o Women United [$250 to $999 to Women United]
o Women’s Leadership Council [$1,000 to $9,999
to Women United]
o Women of Tocqueville [$10,000+ to United Way,
minimum of $1,000 to Women United]
UNITED WAY COPY
Please check the accuracy of all your entries.
Thank you for investing in United Way.
___________________________________________________________________________________________________
United Way of Southeast Louisiana
serving Jefferson, Orleans, Plaquemines, St. Bernard,
St. Tammany, Tangipahoa and Washington Parishes
PLEDGE FORM
Thank you for your contribution to United Way. No goods or services were provided in exchange for this contribution. Please keep a copy of this form for your tax records. You will also need a copy of your year-end
pay stub, W-2 or other employer document showing the amount withheld and paid to a charitable organization. Consult your tax advisor for more information. United Way of Southeast Louisiana will send you a
receipt for payments of $250.00 or more paid in any calendar year by cash, check or credit card. By this contribution you are a member of United Way for the year it is given. This entitles your attendance at the
Annual Meeting and to cast a vote in the election of the Board of Trustees. To ensure the deductibility of your gift, to the fullest extent of the law, designations must be submitted at the same time as your pledge.
COMPANY NAME
MAIN OFFICE 2515 Canal Street, New Orleans, LA 70119
REGIONAL OFFICES St. Tammany PO Box 1750, Covington, LA 70434 | Tangipahoa PO Box 3066, Hammond, LA 70404 | Washington PO Box 217, Bogalusa, LA 70429
o Tocqueville Society [individuals who give $10,000 or more annually]
o Retire United [individuals who are planning to retire or are already retired]
o Young Leaders United [individuals 40 and under who give nancial resources and/or time]
o Volunteering [individuals who give their time]
o Advocating [individuals who spread the word about United Way]
CITY
HOME ADDRESS [REQUIRED FOR CREDIT CARD AND BILLING]
STATE
ZIP
DAYTIME PHONE EVENING PHONE
YOUR INFORMATION
PLEASE PRINT.
oMR oMRS oM I S S
FIRST NAME MI LAST NAME
oMS oDR
o I am a United Way Loyal Contributor (10 years or more). I have contributed to United Way for ________ years.
SPOUSE/PARTNER NAME SPOUSE/PARTNER EMPLOYER
NETWORK OPPORTUNITIES
Check below if interested in learning more on how to get involved or visit UnitedWaySELA.org/getinvolved for more information.
$
o I'm a Fair Share Giver [Check with your coordinator for your company's guidelines.]
For more giving options or to direct your gift towards United Way programs surrounding health, education, or financial stability, please ask your
coordinator for a designation card.
Thank You for contributing to United Way. Please choose your method(s) of payment and total contribution below.
Signature
UnitedWaySELA.org
NON-WORK EMAIL ADDRESS
REQUIRED TO RECEIVE ACKNOWLEDGMENT OF YOUR DONATION
o Check to opt out of UWSELA email distribution lists.
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