United Way of Central PO Box 1357 Highland City, FL 33846-1357 863-648-1500 uwcf.org 1 My Personal Information UWCF respects the privacy of our donors & does not disclose personal information to third parties Prefix: Name: Co. Name: Home Address: Division/Emp. ID #: City: State: Zip: Work Phone: -- Cell Phone: -- Date of Birth: // Preferred Email: My Giving (Select one) 3 My Recognition (Optional) 2 PLEASE LIST MY NAME AS IT APPEARS IN SECTION ONE OR AS FOLLOWS: Option #1 Pledge: Payroll Deduction

I pledge the following each pay period: Preferred Recognition Name

$20 $10 $5 $3 Other: I prefer that my gift remain anonymous Please combine my gift with my spouse

X = Spouse Name $ Pay Periods My total annual gift: $ Spouse’s Employer Option #2 Pledge: One-Time Gift My gift of $1000 or more qualifies me as a LEADERSHIP GIVER Check (Payable to United Way of ) I would like to participate in the Young Leader’s Step-Up program. Cash My total annual gift: $ Please check one: $250 $500 $750 $1,000 I am interested in learning more about other Leadership Step-up programs. Option #3 Pledge: Direct Bill (Minimum gift of $20) Please bill me in the amount of Bill beginning (MM/YY): My Designation (Optional) One-time Monthly Quarterly 4 Option #1: Community Investment My total annual gift: $ The Best Investment. These funds improve lives with a focus on education, income, health and safety net. Over 120 volunteers on 17 Community Investment Teams distribute contributions according to our Option #4 Pledge: Credit Card or Stock Transfer* community’s most critical needs. *For credit card transactions or stock transfers, please contact the United Way office at 863-648-1500. Option #2: Building Blocks for a Better Life Please direct my donation to make measurable change in one My total annual gift: $ or more of the following focus areas:

Education %Income %Health % Safety Net % Option #5 Pledge: My Intent to give via Trust or Foundation* Option #3: UWCF Partner Programs *Intentions to give are not recordable until the check is received from the Foundation. Estimated check date (MM/YYYY) ______/ ______Please direct my donation to the following Partner Programs

% to Designation Code or Partner Program Name Name of Trust/Fund $ % to My total intended gift: Designation Code or Partner Program Name

Option #4: Another 501(c)(3)* My Signature Organization or other United Way. Please use legal/full name.

City State Zip *You may contribute to a specific United Way partner agency or program (see other side for codes), x another United Way or a non-partner agency which provides a well-defined, hands-on health Signature Date or human service and is registered with the IRS as a 501(c)3 in compliance with the Patriot Act.

WHITE COPY: UNITED WAY OF CENTRAL FLORIDA (ECS: INCLUDE WHITE COPIES IN YOUR RECAP ENVELOPE) PINK COPY: COMPANY PAYROLL YELLOW COPY: DONOR COPY (RETAIN THIS COPY FOR YOUR RECORDS. FOR PAYROLL DEDUCTIONS - IN ADDITION TO THE PLEDGE FORM, RETAIN A PAYSTUB, W-2, OR OTHER EMPLOYER DOCUMENT THAT INDICATES THE AMOUNT WITHHELD DURING THE TAX YEAR. REF IRS PUB#1771).

A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL FREE 1-800-435-7352, WITHIN THE STATE. OR BY VISITING 800HELPFLA.COM. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE. THE REGISTRATION NUMBER FOR UNITED WAY OF CENTRAL FLORIDA IS CH-466. UNITED WAY OF CENTRAL FLORIDA RECEIVES 100% OF YOUR CONTRIBUTION. NO GOODS OR SERVICES WERE PROVIDED IN CONSIDERATION IN WHOLE OR IN PART FOR THE FOREGOING GIFTS. DONOR DESIGNATED PLEDGES ARE ASSESSED A FUNDRAISING, MANAGEMENT, AND GENERAL FEE BASED ON ACTUAL HISTORICAL COSTS IN ACCORDANCE WITH UNITED WAY WORLDWIDE MEMBERSHIP STANDARDS AS OUTLINED IN THEIR PUBLICATION TITLED UNITED WAY WORLDWIDE DEDUCTION REIMBURSEMENTS FOR MEMBERSHIP STANDARD M. AMOUNTS REMITTED ARE BASED ON ACTUAL PLEDGE PAYMENTS RECEIVED. United Way of Central Florida’s Contributor Choice Program offers you the opportunity to invest your gift in programs or services of your choice. The majority of individuals contribute through Community Investment #4-Option 1 (see other side) through which your United Way contribution will be used to address our community’s most critical needs. You may choose to invest your gift towards the Focus Area(s) - #4 Option 2 (see other side). #4-Option 3 (see other side) allows you to invest your gift in one or more of our Agency Partner Programs listed below, and #4-Option 4 (see other side) allows you to invest your gift with another 501(c)(3). If no option is selected, your contribution will automatically be put in Community Investment - #4-Option 1.

United Way of Central Florida believes that every child should be given the opportunity to meet his/her potential in school and in life; that everyone should have a fighting chance to support themselves and their families; and that no one can do their best at work or school if they are hungry, sick or in pain. UNITED WE ALL WIN.

Highlands County Family YMCA 38257 InnerAct Alliance 105858 Invest in EARLY CHILDHOOD EDUCATION Summer Camp Scholarship Program 152207 IAA Level Prevention Program 151548 Lake Wales Family YMCA 71126 Lakeland Volunteers in Medicine, Inc. 49163 (Birth - 5 yrs. of age) to help young children After School Care & Summer Camp 152223 Pharmacy Program 152124 enter school ready to read. 1015858 Learning Resource Center of Polk County, Inc. 23242 Targeted Chronic Disease Management 664441 Academic Assistance 151761 Lighthouse for the Blind 10926 Achievement Academy, Inc. 18416 The Salvation Army Serving West Polk County 20164 Independent Living Program 152041 Birth to Three 151381 YES! Youth Education Success 151928 Neighborhood Service Center, Inc. 26591 Central Florida Speech & Hearing Center 18291 United Way of Central Florida Services for Seniors 151795 Speech-Language Pathology 151373 Crystal Lake Elementary Community NU-HOPE Elder Care Services, Inc. 155325 Early Learning Coalition of Florida’s Heartland, Inc. 52597 Partnership School 1337831 Senior Meals (Hardee) 541649 School Readiness (Hardee) 339549 YMCA of West Central Florida, Inc. 7765 Home Delivered Meal Program (Highlands) 330076 Learning Accomplishment Profile (LAP)(Highlands) 695999 Y Reads Success After School Program 152231 Center for Personal Development, Inc. 18903 School Readiness (Highlands) 339507 Y-Readers Summer Learning Program 152256 Children’s Psychiatric Services 151811 Early Learning Coalition of Polk County 65482 Ridge Area Arc, Inc. - Highlands 97220 School Readiness 339531 Invest in FINANCIAL EDUCATION services Residential Services 151142 Sunrise Community of Polk County 97204 Explorations V Children’s Museum 249458 that help individuals and families to have a Storybook Camp 486191 Adult Day Training 152132 Family Literacy Academy at Lake Wales 459768 fighting chance to support themselves and Talbot House Ministries of Lakeland, Inc. 35394 Early Literacy-Family Program 486258 their families. 321240 Good Samaritan Clinic 151985 Lake Wales Family YMCA 71126 Tri-County Human Services, Inc. 65102 Preschool Language & Literacy Development 152215 Church Service Center, Inc. 26740 Agape Halfway House for Women 152082 Learning Resource Center of Polk County, Inc. 23242 Creating Healthy Families 151456 Health Care Educator Drug Abuse Treatment 664466 Camp Ready! 783258 Explorations V Children’s Museum 249458 United Way of Central Florida Lighthouse for the Blind Polk Division 10926 Family Financial Fitness 690370 Crystal Lake Elementary Community Early Intervention (Infants & Children) 440792 Frostproof Care Center, Inc. 103986 Partnership School 1337831 The Salvation Army Serving West Polk County 20164 Financial Fitness 151613 Volunteers in Service to the Elderly (VISTE) 73957 H.A.L.O. Child Enrichment Center 151944 Heart of Florida Legal Aid Society, Inc. 22236 Service to High Risk Seniors 152116 United Way of Central Florida Legal Services (Polk & Hardee) 151886 Dolly Parton Imagination Library 721464 Legal Services (Highlands) 151894 Mulberry Community Service Center 26229 Crystal Lake Elementary Community Invest in SAFETY NET services to help Partnership School 1337831 Financial Stability 151779 Family Fundamentals Parent Resource Center 528760 Personal Finance Center of Polk 1151943 families dealing with a short-term crisis. Master Teacher 1282573 Ridge Area Arc, Inc. - Highlands 97220 608679 Parent Lending Libraries 1337823 Adult Day Training 330159 ReadingPals 1153535 Community Employment 151134 American Red Cross - Highlands 52555 Success By 6 478479 Talbot House Ministries of Lakeland, Inc. 35394 Renewal Program 152009 Emergency Services 151100 The Salvation Army Serving West Polk County 20164 American Red Cross-Polk County Chapter 26690 Invest in ACADEMIC ACHIEVEMENT for Family Living Program 151969 Emergency Services 151076 children at-risk of school failure (grades K-12) United Way of Central Florida Catholic Charities of Central Florida, Inc. 19489 Agape Mission Markets 151258 to help level the playing field for children Crystal Lake Elementary Community Partnership School 1337831 Champion for Children Foundation of living in poverty. 321232 Volunteer Income Tax Assistance (VITA) 1134691 Highlands Co., Inc. 52571 Women’s Care Center of Bartow, Inc. 35469 Prevention Services and Assistance 151423 Big Brothers Big Sisters of Tampa Bay, Inc.- Polk 56242 Transitional Living Center for Women 152165 Emergency Rescue Fund 330126 Comprehensive Mentoring 151167 Women’s Resource Center 35444 Children’s Home Society of Greater Lakeland 367532 Big Brothers Big Sisters of the Suncoast - Highlands 49726 Independence Program for Women 152074 Children’s Advocacy Center (Polk) 151399 One-to-One Mentoring 151605 Good Shepherd Hospice 49122 Boy Scouts Greater Council 19315 The Grief Center 151696 School Based Scouting (Polk & Hardee) 151183 Invest in HEALTH services that reduce the Hardee Help Center 50252 School Based Scouting (Highlands) 151191 need for ER visits and days in the hospital Basic Needs 369561 Boys & Girls Clubs of Lakeland & Mulberry 18275 while also improving a condition specifc HELP of Fort Meade, Inc. 85100 Wogan S. Badcock Jr. Club 151217 First Steps to Financial Stability 151746 Youth Development (3 Lakeland Clubs) 334870 health issue. 321257 Peace River Center for Personal Development, Inc. 18903 Camp Fire USA Sunshine Council 19299 Domestic Violence (Lakeland) 151829 Alliance for Independence, Inc. 18390 Childhood Education & Mentoring Program 151233 Domestic Violence (Highlands) 151837 Adult Day Training 151860 Teen Education & Mentoring Program 1016286 Rape Recovery & Resource Program (Polk) 151852 Residential Services 151878 Citrus Center Boys & Girls Clubs 26658 Talbot House Ministries of Lakeland, Inc. 35394 Catholic Charities of Central Florida, Inc. 19489 George W. Jenkins Memorial Complex 151472 Emergency Shelter/Basic Needs 151977 Lakeland Activity Center for Seniors 151308 South Ridge Unit 333963 The Salvation Army of East Polk 26559 Central Florida Speech & Hearing Center 18291 North Ridge Unit 151480 Shelter for Women & Children 152017 Audiology for Kids (Polk) 151340 Girl Scouts of West Central Florida - Polk 17962 Social Services 152025 Audiology for Adults (Polk) 433235 Traditional Troop Membership 151647 The Salvation Army Serving West Polk County 20164 Champion for Children Foundation Staff Led Outreach 4 4 9 8 3 5 Family Emergency Efficiencies 151936 of Highlands Co., Inc. 52571 Girls Inc. of Lakeland 19075 United Way of Central Florida Vision Quest 151431 Building Strong, Smart & Bold Girls 151621 2-1-1 Information & Referral Service 1153337 Epilepsy Services West Central FL 64022 Girls Inc. of Winter Haven 26633 Crystal Lake Elementary Community Targeted Case Management (Polk) 151563 After School & Summer Program 151639 Partnership School 1337831 Good Shepherd Hospice 49122 Hardee County Family YMCA 2162 Newspaper with a Heart Partnership 423467 Caregiver Program 151688 After School - Adventure Club 152181 Youth and Family Alternatives, Inc. 4317 Heartland Horses Equine Activities - Highlands 330134 Summer Program - Adventure Club 581785 George W. Harris Youth Shelter (Polk) 152272 Horse Therapy 330142 Highlands County Boys & Girls Club 462150 George W. Harris Youth Shelter (Highlands) 152280 Project Learn 696005

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United Way of Central Florida Post Office Box 1357 Highland City, FL 33846-1357 Telephone: 863.648.1500 Fax: 863.648.1535 United Way of Central Florida Highlands County Division Post Office Box 3860 Sebring, FL 33871-3860 Telephone: 863.414.6224 United Way of Central Florida