2019 MSA United Way Payroll Form - Bismarck Public Schools (14 Pay Periods)

Amount per 14 pay periods

Total Amount

Missouri Slope Areawide United Way Pledge Form

My Contact Information

Prefix

First Name *

Middle Initial *

Last Name *

Gender *

Birth Date *

Home Address *

City *

State *

ZIP *

Work Phone *

Company Name *

Personal Phone *

Preferred Email *

Recognition

I am a Loyal Contributor, I have been investing in my community with United Way since:

My contribution is part of a household investment. Please combine my gift with my spouse/family member:

Yes No

Spouse/Family Member Name

Spouse/Family Employer

Combined Total (enter in dollar amount)

Please recognize my/our name as follows

Recognition

I would like to designate my $5,000+ gift to the MSA United Way Endowment Fund (contact your accountant for available tax credits).

I prefer that my/our gift remain anonymous.

My/our gift of $500+ qualifies for membership in the Hero Club.

I would like to be recognized as a member of Women United with my gift of $500+.

I'm interested in becoming a volunteer reader, tutor or mentor.

I have included United Way in my will/estate plans.

I'm retiring this year.

Hero Club

Bronze - $500 - $749     Silver - $750 - $1,499
Gold - $1,500 - $2,499     Platinum - $2,500 - $4,999
24-Karat - $5,000 - $9,999     Tocqueville - $10,000+

Women United

Emerald - $500 - $749 Ruby - $750 - $1,499
Sapphire - $1,500 - $2,499 Diamond - $2,500 - $4,999
Hope Diamond - $5,000+

Payment Options

[x] Payroll Deduction

Optional - Pledge Designations

Choose how you want to invest in your community. Please enter an amount in the fields provided below.

MSA United Way (General Community Needs)

MSA United Way Emergency Homeless Shelter

Education

Help children achieve their potential through education.

Imagination Library

Ensure that children are prepared for school ($25 provides a local child with one free book each month for a year.)

Income

Help families become financially stable and independent.

Create a Hunger-Free ND

Combat hunger (backpack program, food pantries)

Health

Promote healthy choices and active lifestyles for all.

Please designate this amount to the agency of my choice

Agency of Choice

Agency Listing

MSA United Way Endowment Gift

I would like my gift to go to United Way's Endowment Fund.