Use this form to pledge your contribution to the United Way of Montcalm County.

This form will inform the United Way and create a printable form for you
to print and send in with your signature to verify your pledge.  You will be contacted
about your pledge shortly.

YES!  I want to help Build Caring Communities in Montcalm County!

Name -
Address -
City -	State -   Zip -
Phone (work)	Company -
Email -

Check all that apply:

My combined household pledges total $250 or more, and I would like to be
     acknowledged publicly as a Leadership Giver

I am interested in volunteering for a United Way agency.  Please contact me
     by phone at -

I would like to designate my pledge and authorize release of my name to these
     specific 501(c)3 agencies or another United Way:
    
     Please include the name and address of the agency designated if possible.

Payroll Deduction Authorization (per pay period) $2 $5 $10 Other - $ I am paid: Weekly (52) Monthly (12) Every two weeks (26) Twice monthly (24)

Annual Gift / Direct Bill Annual Pledge $ Paid Now       $ Balance           $ Payment Enclosed To be billed annually