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X X United Way of Central Florida United Way of Central Florida 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: 2 My Giving (Select one) 4 My Recognition (Optional) Option #1 Pledge: Payroll Deduction PLEASE LIST MY NAME AS IT APPEARS IN SECTION ONE OR AS FOLLOWS: 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: $ Option #2 Pledge: One-Time Gift Spouse’s Employer Check (Payable to United Way of Central Florida) My gift of $1000 or more qualifies me as a LEADERSHIP GIVER Cash My total annual gift: $ I would like to participate in the Young Leader’s Step-Up program. Please check one: $250 $500 $750 $1,000 (Minimum gift of $20) Option #3 Pledge: Direct Bill I am interested in learning more about other Leadership Step-up programs. Please bill me in the amount of Bill beginning (MM/YY): One-time Monthly Quarterly My Designation (Optional) My total annual gift: $ 5 Option #1: Community Investment Option #4 Pledge: Credit Card or Stock Transfer* The Best Investment. These funds improve lives with a focus on education, income, health and safety net. Over 120 volunteers on 18 *For credit card transactions or stock transfers, please Community Investment Teams distribute contributions according to our contact the United Way office at 863-648-1500. community’s most critical needs. My total annual gift: $ Option #2: Building Blocks for a Better Life Please direct my donation to make measurable change in one My Signature (Required for my giving) or more of the following focus areas: x Education %Income %Health % Safety Net % Signature Date Option #3: UWCF Partner Programs Please direct my donation to the following Partner Programs My Intent to give via Trust or Foundation* % to 3 Designation Code or Partner Program Name *Intentions to give are not recordable until the check is received from the Foundation. % to Estimated check date (MM/YYYY) _________ / __________ Designation Code or Partner Program Name Name of Trust/Fund Option #4: Another 501(c)(3)* My total intended gift: $ Organization or other United Way. Please use legal/full name. My Signature (Required for my intent) City State Zip x *Contingent upon the organization meeting the eligibility requirements for 501(c)(3) status as determined by the Internal Revenue Code & submitting a signed USA Patriot Act Compliance Signature Date Form to UWCF. 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 #5 - 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) - #5 Option 2 (see other side). #5 Option 3 (see other side) allows you to invest your gift in one or more of our Agency Partner Programs listed below, and #5 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 - #5 Option 1. United Way of Central Florida works with partners to produce measurable, sustainable change. You can help! Highlands County Boys & Girls Club 462150 Good Shepherd Hospice 49122 EDUCATION: Early Literacy Initiative Project Learn 696005 Caregiver Program 151688 Help to improve the percentage of children Highlands County Family YMCA 38257 Heartland Horses Equine Activities - Highlands 330134 Summer Camp Scholarship Program 152207 Horse Therapy 330142 who enter school ready to read. Lake Wales Family YMCA 71126 InnerAct Alliance 105858 After School Care & Summer Camp 152223 IAA Level Prevention Program 151548 Achievement Academy, Inc. 18416 Learning Resource Center of Polk County, Inc. 23242 Lakeland Volunteers in Medicine, Inc. 49163 Birth to Three 151381 Academic Assistance 151761 Pharmacy Program 152124 Central Florida Speech & Hearing Center 18291 The Salvation Army Serving West Polk County 20164 Targeted Chronic Disease Management 664441 Speech-Language Pathology 151373 YES! Youth Education Success 151928 Lighthouse for the Blind 10926 Early Learning Coalition of Florida’s Heartland, Inc. 52597 Webber International University - Highlands 279737 Independent Living Program 152041 School Readiness (Hardee) 339549 High School Academic Success Program 696013 Neighborhood Service Center, Inc. 26591 School Readiness (Highlands) 339507 YMCA of West Central Florida, Inc. 7765 Services for Seniors 151795 Learning Accomplishment Profile (LAP) 695999 Y Reads After School Program 152231 NU-HOPE Elder Care Services, Inc. 155325 Early Learning Coalition of Polk County 65482 Y-Readers Summer Program 152256 Senior Meals (Hardee) 541649 School Readiness 339531 Home Delivered Meal Program (Highlands) 330076 Explorations V Children’s Museum 249458 Peace River Center for Personal Development, Inc. 8903 Storybook Camp 486191 INCOME: Financial Stability Children’s Psychiatric Services 151811 Ridge Area Arc, Inc. - Highlands 97220 Family Literacy Academy at Lake Wales 459768 Help low-income families to manage debt, earn Early Literacy-Family Program 486258 Residential Services 151142 Lake Wales Family YMCA 71126 job credentials, and build savings. Sunrise Community of Polk County 97204 Preschool Language & Literacy Development 152215 Adult Day Training 152132 Learning Resource Center of Polk County, Inc. 23242 Catholic Charities of Central Florida, Inc. 19489 Talbot House Ministries of Lakeland, Inc. 35394 Camp Ready! 783258 Family Empowerment (Polk) 151290 Good Samaritan Clinic 151985 Lighthouse for the Blind Polk Division 10926 Church Service Center, Inc. 26740 Tri-County Human Services, Inc. 65102 Early Intervention (Infants & Children) 440792 Creating Healthy Families 151456 Agape Halfway House for Women 152082 Polk County Public Schools Explorations V Children’s Museum 249458 Health Care Educator Drug Abuse Treatment 664466 Early Warning Response System (EWRS Success Coach) 1054873 Family Financial Fitness 690370 Volunteers in Service to the Elderly (VISTE) 73957 The Salvation Army Serving West Polk County 20164 Florida Prosperity Partnership - Polk 517177 Service to High Risk Seniors 152116 H.A.L.O. Child Enrichment Center 151944 Leadership Program Family Financial Stability 792622 United Way of Central Florida Matched Savings for Assets 916866 Dolly Parton Imagination Library 721464 Free Tax-Prep Coordinator 459602 SAFETY NET: Help to stabilize families in Family Fundamentals Parent Resource Center 528760 Frostproof Care Center, Inc. 103986 crisis by providing short-term emergency Master Teacher 399196 Financial Fitness 151613 Parent Lending Libraries 382192 Heart of Florida Legal Aid Society, Inc. 22236 support. ReadingPals 1153535 Legal Services (Polk & Hardee) 151886 Success By 6 478479 Legal Services (Highlands) 151894 American Red Cross - Highlands 52555 Mulberry Community Service Center 26229 Emergency Services 151100 Financial Stability 151779 American Red Cross-Polk County Chapter 26690 EDUCATION: Academic Achievement K-12 Credit Repair/Debt Reduction Center 1151943 Emergency Services 151076 Help to improve school attendance, promotion Ridge Area Arc, Inc. - Highlands 97220 Catholic Charities of Central Florida, Inc. 19489 rates, and reading, math, and science scores. Adult Day Training 330159 Agape Food Bank 151258 Community Employment 151134 Champion for Children Foundation of Talbot House Ministries of Lakeland, Inc. 35394 Highlands Co., Inc. 52571 Big Brothers Big Sisters of Tampa Bay, Inc.- Polk 56242 Renewal Program 152009 Prevention Services and Assistance 151423 Comprehensive Mentoring 151167 The Salvation Army Serving West Polk County 20164 Emergency Rescue Fund 330126 Big Brothers Big Sisters of the Suncoast - Highlands 49726 Family Living Program 151969 Children’s Home Society of Greater Lakeland 367532 One-to-One Mentoring 151605 United Way of Central Florida Advocacy Center
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