Organization Name

GIVE DIRECTLY TO UNITED WAY COMMUNITY INVESTMENT

PLEASE SELECT YOUR METHOD OF INVESTING

UNITED WAY LEADERSHIP GIVING

MR/MRS/MS/DR FIRST NAME MI LAST NAME

STATE ZIPHOME ADDRESS (For credit card charges and bill me options, your billing address is required.) CITY

COMPANY NAME EMPLOYEE ID NUMBER DAYTIME PHONE

HOME PHONE

White Copy - United Way Yellow Copy - Company Pink Copy - Employee

I have been a loyal contributor to the United Way Campaign since . ( y y y y )

My leadership gift or combined household gift of $1,000 or more qualifies me for membership in the Constitution Society.

Spouse/Partner gift amount:

Spouse/Partner name:

Employer:

Please list my/our name(s) as follows: I/We prefer our leadership gift to remain anonymous.

SIGNATURE (REQUIRED) DATE

FRID ID # _________________

(for Campaign use only) 0815-50K

SUPPORT ALL FOUR UNITED WAY COMMUNITY INVESTMENT PRIORITY AREAS

THANK YOU FOR LIVING UNITED!

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PERSONAL E-MAIL ADDRESS

UNITED WAY CAMPAIGN30 Laurel Street Hartford, CT 06106

860-493-6800

EDUCATION Support local children to be successful academically and in life.

FINANCIAL SECURITY Support local families to become financially secure.

BASIC NEEDS Ensure everyone has access to immediate emergency assistance, such as food and shelter.

UNITED WAY MEMBERSHIP OPPORTUNITIES

Organization address and phone number. Please see reverse for more details.*

I would like to JOIN/RENEW the following membership(s):

Neighborhood Arts and Heritage — Diversity through arts and culture programs in Greater Hartford.

Please check here if you want to be acknowledged by the organization to which you have directed a gift.

MOBILE PHONE PREFERRED FORM OF CONTACT

Facebook.com/unitedwayinc@unitedwayinc

Direct your contribution to another organization.

Or focus your gift on one or more of the following priority areas:

COMPANY LOCATION

JOIN THE CONVERSATION:unitedwayinc.org

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OPTIONAL DIRECTED GIFTS *See reverse side for details.

United Way Women’s Leadership CouncilAn additional gift of $250, $500 or $1000 qualifies you for membership. Contributions support the Council’s work in financial security and education.

United Way Emerging Leaders Society A contribution of $50 or more to United Way Community Investment qualifies you for membership. Contributions support the Society’s work in education.

I want my contribution to benefit all United Way partners with the exception of:

HEALTH Improving lives of people affected by disability or chronic disease.

TOTAL GIFT $

CREDIT CARD BILL ME

o One time $ ______________ processed upon receipt by United Way

o Monthly $ ______________ per month (starting March 2016)

o Quarterly $ ______________ per quarter (starting March 2016)

o VISA o MC o AMEX o Discover

CREDIT CARD NUMBER EXP. DATE

NAME ON CARD PHONE #

PAYROLL DEDUCTION

I WILL CONTRIBUTE $ PER PAY PERIOD

I receive my paycheck:

o Weekly (52/year)

o Every Two Weeks

o Semi-Monthly (24/year)

o Monthly

I authorize my employer to deduct my total annual contribution from my paycheck in equal amounts.

CHECK CASH

Enclosed is my check payable to the United Way Campaign.

$ TOTAL

CHECK #

o SECURITIESPlease call United Way to transfer funds at 860-493-6800.

HOME ADDRESS REQUIRED FOR THESE PAYMENT OPTIONS

AMOUNT $

AMOUNT $

AMOUNT $

AMOUNT $

AMOUNT $

AMOUNT $

AMOUNT $

AMOUNT $

HOW YOUR CONTRIBUTIONS ARE DISTRIBUTEDCONTRIBUTIONS DIRECTED TO ORGANIZATIONS through United Way are subject to a 10 percent fee (includes administration and fundraising costs), capped at $100 per directed gift (assessed on a pro-rata basis upon gift proceeds received). No fees are deducted by United Way from contributions to Community Health Charities, or any Community Health Charities Federation or their member charities. Community Health Charities deducts its own administrative fee prior to dis-bursement of these gifts.

PAYROLL DEDUCTION CONTRIBUTIONS will be distributed directly to designated organizations in April, July, October, and December 2016, and March and June 2017, if proceeds and pledge details are received by United Way on or before the end of the month preceding payout.

CHECK, CREDIT CARD OR STOCK payments will be distributed to directed organizations by February 28, 2016, if proceeds and pledge details are received by United Way on or before December 31, 2015.

UNDESIGNATED CAMPAIGN PLEDGES will be distributed through United Way and Community Health Charities as agreed upon by both organizations.

THANK YOU FOR YOUR CONTRIBUTION! If you selected United Way Community Investment or related priority areas (education, financial security, health, basic needs) as your investment of choice, thank you. You are helping create measurable, lasting change in the lives of local children and families. Please keep a copy of this form for your tax records. You will also need a copy of your paystub, W-2 or other employer document showing the amount withheld and paid to a charitable organization. Consult your tax advisor for more information.

No goods or services were provided in exchange for this contribution.

*OPTIONAL DIRECTED GIFTS Thank you for your contribution to the 2015 United Way Campaign. United Way of Central and Northeastern Connecticut is honored to partner with your employer in helping employees give back to issues they care about. You may direct a portion or all of your gift to any qualified not-for-profit organization recognized as a 501(c)(3) by the Internal Revenue Service. You must include the organizations’s name, address and phone number.

If you selected an organization to receive your contribution, we will verify that it is U.S. Patriot Act compliant and certified by the Internal Revenue Service as a 501(c)(3) or other tax-exempt organization. If we cannot locate your directed organization, or if it is not an IRS qualified 501(c)(3) organization that is Patriot Act Compliant, we will make every reasonable attempt to contact you. Please note that such restricted gifts are not monitored by United Way of Central and Northeastern Connecticut or Community Health Charities.

For a list of local United Way and Community Health Charities partner organizations, please visit unitedwayinc.org/partners.

United Way of Central and Northeastern Connecticut 30 Laurel Street Hartford, CT 06106 unitedwayinc.org

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