United Way of Southeastern Kentucky
Pledge Card

1. Please print this form and fill out the information requested. Your social security number is necessary if your donation is through a payroll deduction plan. Be sure to designate your gift for United Way of Southeastern Kentucky in general, for a specific county, or for a specific United Way member agency.
2. Please clip along the lines and return this pledge card to the local United Way representative at your place of employment. Your United Way representative will then turn in all completed pledge cards to your payroll department.
3. If your place of employment is not participating in this United Way campaign, you can still participate with a direct pay donation. Please return this pledge card to United Way of Southeastern Kentucky, 917 Perry Park Road, Hazard, Kentucky 41701

For your records:
Amt. of donation____________ Check Number______________ Date of donation____________
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United Way Pledge Card

Name__________________
Address________________
State__________________ 		SSN___________________
City___________________
Zip Code_____________ 		Designate my gift for:
(please check one only)
or Direct Pay  
I authorize my employer to deduct:
[ ] One hour pay per month
[ ] Pledge per pay period
[ ] $25 [ ] $15 [ ] $10
[ ] $5 [ ] $3 [ ] $______
TOTAL PLEDGE for year:
$____________ 		Total Pledge..........$________
Cash Paid Now.....$________
Balance Due..........$________
Please bill me ($25 min.)
[ ] quarterly
[ ] semi-annually
[ ] once __________ 		[ ] United Way of Southeastern Kentucky
[ ] Breathitt County
[ ] Knott County
[ ] Lee County
[ ] Leslie County
[ ] Letcher County
[ ] Owsley County
[ ] Perry County
[ ] Wolfe County
[ ] United Way Member Agency
_________________________
Signature_________________   Date___________________

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