2019 Pledge Form | United Way of Defiance County

2019 Pledge Form

First Name

Last Name

Street Address

City

State

Postal Code

Phone

Email

Company Name

Other

My pay period is

Weekly (52 payments)

Biweekly (26 payments)

Semimonthly (24 payments)

Monthly (12 payments)

Bill Me (fill in $ amount)

Via

Mail Email

This often

414 Giving Society ($500+ Annually)

My total gift (at or above $500) qualifies me for the 414 Giving Society.

I would like to combine my gift with my spouse's gift to qualify for the 414 Giving Society.

Spouse's/Partner's First and Last Name

Spouse's/Partner's Employer

How do you want your name(s) to appear in our publications?

I/We wish my/our gift to be anonymous

Yes

No

Please choose how to invest in your community:

Education

Financial Stability

Health

Let us choose the area of greatest need

Optional: List the agency name, address and donation amount here.

Specific Agency Designation