IDAHO STATE EMPLOYEES’
CHARITABLE GIVING CAMPAIGN
Thank you for your donation. Please complete this form, print, sign, make
a copy for your files and give it to your agency Campaign Coordinator.
Please check the United Way region in which you work
Moscow Area – 560
Lewiston Area – 561
Panhandle/Coeur d’Alene – 573
SW Idaho/Treasure Valley – 564
South Central Idaho/Twin Falls – 570
Other
Pocatello/Southeastern Idaho – 567
Idaho Falls Area – 558
My pledge authorization
I pledge a total gift of $ Signature Date
This is 1% of my gross income
This is 2% of my gross income
This is 1/2% of my gross income
remain anonymous
Here’s how I’d like to make my donation
Payroll Deduction (Starting in Jan. 2016 unless requested otherwise)
Please Bill Me (Starting in Jan. 2016 unless requested otherwise)
Monthly
Quarterly
Other
1st Pay Period
12
x
$_
=
$
2nd Pay Period
12
x
$_
=
$
Every Pay Period
26
x
$_
=
$
Cash/Check
:
I
pledge
a
total
gift
of
$_
Please make check payable to the United Way Regional Office you selected above.
Tax-Exempt Charitable Organization(s) to which I designate my gift (if you wish to add more
organizations, please print an additional form)
Organization (and address if not local)
$
$
$
I authorize my name and address released to the organization(s) above.
Visit the State Employees’ Charitable Giving Campaign Web site at www.unitedwecare.idaho.gov
