Full Name

First Name

Last Name

Email

Cell Phone

Address

Address 1

Address 2

City

ZIP Code

State

Total Pledge

Check/Cash Donation

Pledge Amount

Make checks payable to Sioux Empire United Way. Please give the check to your Campaign Coordinator.

Total Pledge

Amount

Total Pledge

Payment

This payment is for a one time donation for the amount above.

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Payment

This payment will set up a recurring donation of the amount above.

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Bill Me Options

Pledge Amount

Frequency of Invoice

One Time

Quarterly

Total Pledge

Check all that apply

I'd like to receive monthly emails about the impact of my gift.

My gift qualifies me for recognition as a Rising Heart or Heart Club member.

I would like to combine my pledge total with my spouse for Heart Club recognition

Spouse's Name and Employer

Signature

My signature below, confirms my pledge as stated above.

Example Campaign Form with Payroll