MR/MRS/MS/DR
FIRST NAME
MI
LAST NAME
CITY
HOME ADDRESS (For credit card charges, address listed must be your billing address.)
STATE
ZIP
HOME PHONE
1331 Euclid Avenue
Cleveland Ohio 44115
216-436-2100
unitedwaycleveland.org
DAYTIME PHONE
DATE OF BIRTH
COMPANY NAME
-
HOME EMAIL ADDRESS
United Way of Greater Cleveland mobilizes people, organizations and resources in a focused effort
to advance education, income and health in our Greater Cleveland community.
You can help. Please complete this form and return it to your Employee Campaign Manager
(be sure to retain a copy for yourself). See the reverse side for optional designation instructions.
m I am a Loyal Contributor I have been giving to United Way since YEAR (APPROX.)
OR ❍ 10+ years ❍ 25+ years
My total gift amount: $_____________________________________________________
(Become a member of our Humanitarian Society with your gift of $1,000 or more)
My gift will be paid as indicated:
m Easy payroll deduction
m Cash or personal check (make checks payable
to United Way of Greater Cleveland)
My pay period:
❍ Weekly (52)
❍ Every two weeks (26)
❍ Twice a month (24)
❍ Monthly (12)
My pledge per pay period:
❍ $50 ❍ $30 ❍ $20
m Bill me ($50 minimum)
m Donated securities (call 216-436-2132
when you are ready to transfer funds)
❍ $10
$___________________________
m Credit card
$______________
ESTIMATED AMOUNT
m VISA m Mastercard
-
ACCOUNT NUMBER
EXP. DATE
INFLUENCE THE CONDITION OF ALL. United Way’s Community Impact Fund.
Please check here
3
$_______________
I want to make the best choice for my community and direct my gift to
the Community Impact Fund. This is the most powerful way to create
a healthy community where every child graduates and every individual
and family achieves financial stability.
To designate a portion of your pledge, please also complete the
Optional Donor Designation Form on the reverse side.
SIGN HERE TO AUTHORIZE YOUR PLEDGE
DATE
Thank you for your contribution to United Way of Greater Cleveland!
IRS Declaration: No goods or services were provided in exchange for this contribution. Receipts for nonpayroll contributions in the amount of $100 or more will be mailed in January of the year following payment.
Retain a copy of this signed and dated pledge form for your tax records. You will also need a copy of your
pay stub, W-2 or other employer document showing the amount withheld and paid to a charitable
organization. Consult your tax adviser for more information. Checks may be deposited electronically.
Optional donor designation form
It is not necessary to complete this designation form if you already have directed
your gift to the Community Impact Fund. To designate all or a portion of your gift,
please review the designation policies at left before completing this form.
United Way Designation Options
COMMUNITY IMPACT AREAS You may direct your donation to one or more of the
following impact areas: (no minimum required)
m EDUCATION: Preparing children to enter school ready
Donor Designation Policies
If you directed your gift to the Community Impact
Fund, your pledge form is complete. Thank you.
If you wish to direct a portion of your pledge to an
area or a specific agency please see below.
COMMUNITY IMPACT AREAS: You may direct all
or a portion of your gift to one or more of United
Way’s impact areas, products or affinity groups.
OPTIONAL RESTRICTED CONTRIBUTIONS: You may
direct all or a portion of your contribution to one
or more United Way of Greater Cleveland partner
agency(ies) or another United Way. The minimum
pledge is $50.
You may direct up to half of your contribution
to a maximum four 501(c)(3) health and human
service non-affiliated agency(ies) located in and
serving Northeast Ohio. You may choose United
Way options for the balance of your pledge.
All designated agencies must comply with the
USA Patriot Act and other counterterrorism laws.
If you designate to an agency not in compliance,
we will attempt to contact you. If we cannot reach
you, we will direct your gift to the Community
Impact Fund.
(Capital campaigns, cultural, political,
environmental, governmental, private schools
and universities, or religious organizations are
not eligible to receive designations.)
Designations will be paid to agencies quarterly
minus a small processing fee. United Way has a
fiduciary responsibility to respond to questions
regarding these payments.
Greater Cleveland respects your privacy and does
not rent, trade or sell your information. It is used
to record contributions and to communicate with
you. Information may be shared with designated
agency(ies).
If one or more of your designations do not meet
our requirements, we will make every effort to
contact you. If we cannot reach you, your gift will
be directed to the Community Impact Fund.
150704/75K
$______________
(6276785)
to learn and graduate from high school
•Improving access to quality, affordable child care and
early learning opportunities
•Partnering with schools and parents to improve graduation rates
•Providing after-school and mentoring programs for at-risk youth
m INCOME: Advancing individuals and families to financial empowerment $______________
•Supporting basic needs while increasing financial education
•Helping hardworking people obtain job training and family-sustaining wages
•Increasing affordable housing for seniors and families
m HEALTH: Building a healthy and resilient community
•Increasing access to critical health care services
•Reducing substance abuse, child abuse and domestic violence
•Increasing health education and preventive care
(6276786)
$______________
(6276787)
and/or
m Women’s Leadership Council: The Women’s Leadership Council (WLC) supports early learning
initiatives to help ensure all children in Greater Cleveland have access to quality education.
The WLC is open to any woman who directs $250 or more of her annual United Way
donation to the WLC. Learn more at unitedwaycleveland.org/wlc.
Executive Leader ($1,000+)
$______________
Associate Leader ($500-$999)
$______________
Emerging Leader ($250-$499)
$______________
m Young Leaders: Your donation will support United Way’s work being driven by Young Leaders, a group of professionals,
ages 20 through 40, who give, advocate and volunteer to advance
education, income and health. Learn more and get involved at
$______________
(6276951)
(6276951)
(6276951)
(6290644)
unitedwaycleveland.org/youngleaders.
m United Way 2-1-1: You may direct all or a portion of your donation to United Way 2-1-1, a free community service directing people
to information about social, health and government resources
24/7. Learn more at 211oh.org.
$______________
m Schools Implementing Wraparound Strategy: Support United Way and
CMSD’s partnership to provide social services to kids in low
performing schools. By addressing non-academic issues such
as absenteeism, behavior and health, barriers to learning are
removed. Learn more at LiveUnitedForKids.org.
$______________ (270)
(6290645)
and/or
Optional Restricted Contribution: Designations must be at least $50. Designations to non-partner
agencies may not exceed four agencies nor total more than 50 percent of the total pledge.
See designation policies on the left.
AGENCY NAME AND ADDRESS
________________________________________________________
$______________
$50 MINIMUM
Thank you for your support!