1 Start 2 Complete My Contact Information Mr/Mrs/Ms/Dr * - Select -Mr.Mrs.Ms.Dr. First Name * Last Name * Home Address * City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Workplace / Employer * Email Address * Cell Phone * Office Phone Payment Information Donation Payment Options (Select One) Payroll Deductions One-Time Cash or Check Bill Me (one-time or recurring) Amount per Pay Period Please indicate how often you are paid: Please indicate how often you are paid: WEEKLY (52 times/yr) BI-WEEKLY (26 times/yr) SEMI-MONTHLY (24 times/yr) OTHER If other, what frequency: Cash or Check Make any checks payable to United Way of Central WV. CASH CHECK Amount of Cash or Check Billing Interval ONE-TIME MONTHLY QUARTERLY If one-time, how much should we bill? If monthly, how much should we bill each month? If quarterly, how much should we bill each quarter? Billing Options E-mail the invoice(s) Mail the invoice(s) to the address provided My total annual gift is: * $ Capitol Club Leadership Giving Society United Way encourages leadership giving. A gift of $500 or MORE qualifes you for membership in the Capitol Club Leadership Giving Society. We will recognize your individual or combined leadership gift. Please indicate how your name(s) appear in publication: Name(s) Company Affliation(s) Identification I/we wish to remain anonymous. Do not release my/our name. Combined Gifts If this is part of a combined gift, please provide the other person’s info below. Name Gift Amount $ Designate My Contribution To Verification Type Your Full Name as Verification of your Submission * Date * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20192020 Year Please check the accuracy of all your entries and make a copy for your tax records. United Way does not provide goods or services as whole or partial consideration for any contribution. Donor does not expect to receive a nancial or economic bene t as a result of this contribution. West Virginia resident may obtain a summary of the contribution and nancial documents from the Secretary of State, State Capitol, Charleston, WV 25305. Contribution does not imply endorsement. Submit
