Pledge Form My InformationPrefixMr.Mrs.MissMs.Dr.Prof.Rev.Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code EmployerEmail Address* Would you prefer that we contact you on your home or work number?HomeWorkPlease enter your home or work phone number*Payment OptionsMy total Annual Pledge*Please enter dollar amount. Payroll Deduction $1/Week ($52) $2/Week (104) $5/week ($260) $10/week ($520) If you are a new donor, please consider one of the following optionsPayment Options Cash (to be remitted to the United Way of Central Va office 1010 Miller Park Square Lynchburg, Va 24501) Check (made payable to United Way of Central Va) Stock $ (Call UWCV for assistance 434-455-6902) One time payroll deduction Bill me Enter date for deduction Credit CardAmount to be charged to credit card $A team member from the United Way staff will contact you to process your credit card. Frequency of amount to be charged to credit card $ Monthly Quarterly One time My ImpactPlease choose one of the following (to select multiple options, hold down the shift key):*COMMUNITY PROGRAMS Programs under our impact areas: Education, Health and IncomeEDUCATION READINESS INITIATIVEOTHER Must be a 501(c)3 agency. You must provide address and contact information.($50 minimum donation required for each designation)If you selected Community Programs enter donation amount here $:If you selected Education Readiness Initiative enter donation amount here $:If you chose other, please enter the agency and dollar amount here**Leadership GivingLeadership gifts ($500+) show that you are committed to improving the quality of life in our community. United Way of Central Virginia would like to recognize individuals and couples who are Leadership Givers.Please make your selection Please recognize me/us in printed materials as: I would like to combine this year’s gift with my spouse’s gift. I/We wish to remain anonymous. If you selected recognize me/us in printed materials, enter your name here:If you selected to combine this year's gift with my spouse's gift, enter spouse's name here:I have been a Loyal Contributor to United Way for: 5-9 years 10-24 years 25 + years Please select one of the following I am interested in serving on a Fund Distribution Review Team I am interested in Volunteer opportunities. I would like information about the Planned Giving Program. I am interested in the Young Leaders Society (age 18-40) My Total Annual Pledge $*Signature*By typing your name here, you authorize this pledge. *IRS Tax Guidelines mandate that taxpayers who wish to deduct contributions through payroll deduction must retain pay stub, Form W-2 or other document furnished by employer that shows the total amount withheld for payment to charity, along with the pledge form that shows the name of the charity. No goods or services were received in exchange for this gift.