PAYROLL DEDUCTION Click here to complete a Pledge form for payroll deduction. This form need to be printed and return to your campaign coordinator or the payroll department. WORKPLACE PLEDGE CARD Preferred Donation Method Payroll Deduction Check Cash Credit Card / Debit Payroll Deduction Contribution Amount Per Pay Period $5 $10 $20 $25 $50 Other… $ Number of Pay Periods for Donation One Time 12 pay periods 24 pay periods 26 pay periods 52 pay periods Other… $ TOTAL: $0 Update Check Donation Amount of Check $ Cash Donation Amount of Cash $ Credit / Debit Card Donors: Thank you for your support of the United Way. To complete your donation by credit or debit card - please click here. Your Name Title First Middle Last Suffix Your Contact Information Company Email Phone Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP Code Designations Invest My Donation In... Impact Fund Education Fund Financial Stability Fund Health Fund Basic Need Fund Emergency Fund Agreement My signature below, confirms my payroll deduction request as stated above. Signature Reset Submit CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.