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									                  United Way of Greater Victoria                       PLEDGE FORM
                  1144 Fort Street
                  Victoria, B.C. V8V 3K8
                  Ph: 250-385-6708 Fax: 250-385-6712
                                                    Employee Number:_______________________________
                  Charitable Bus.#119278224RR0001

  Name:                                                                                            Leadership Recognition
                                                                                              Community Leaders         $500 - $999
  Department:                                                                                         minimum $21 per pay

                                                                                              Leaders of the Way     $1,000 - $2,499
  Email, Phone, Home Address (Optional):                                                               minimum $42 per pay

                                                                                              Pioneers                  $2,500 - $4,999
  ____________________________________________________                                                   minimum $105 per pay

                                                                                              Patrons                          $5,000 - $9,999
  Red Feather Friends                                                                         Pathfinders                   $10,000 - $24,999
  The Red Feather recognizes United Way supporters and volunteers
                                                                                              Benefactors                             $25,000+
  of 25+ years.
  I have supported United Way since:________________________
                                                      Yes, I want to support United Way!
United Way is addressing issues of Family & Community Well-being, Housing for Homeless, Low Income & Working Poor, Mental Health & Addictions

                        PLEDGE PAYMENT OPTIONS
                                                                                                               My Total Donation is:
 A         Payroll Deduction             B          Direct Contribution
  q Please deduct from my                 q   Cash         q Cheque                                         $___________________
  pay 24 equal installments of:           q   Credit Card: q VISA q M/C q AMEX
  q                                       q   One Time (min. $25)
                                          q   Monthly: ($________x 12, min. $10/month)                            Donor Signature
  q                                       (Monthly installments, Jan.15 - Dec.15, or next
                                          business day.)
                                          Card#____________________________                           Date______________________
  q Other:                                Exp.____________________                                      Authorizing payroll deduction, credit card
                                          q   Please continue my monthly donation until I                charge or automatic bank deduction.
          $_________per pay
                                              tell you to stop.
          x_______pay periods             q Automatic Bank Deductions                                              THANK YOU!
                                          Please deduct $________ (min.$10/month) on the 15th                       for your gift
                                          day of each month or next business day starting Jan. 2011
                                                                                                      Tax receipts – Receipts for payroll gifts are
                                          for the period of one year (Attach a voided cheque – you
                  yy/mm                                                                                included on T4 slips. Receipts for cash/
                                          may revoke authorization at any time, subject to notice.)   cheque/credit card gifts of $25+ distributed
                                                                                                       by Feb. 28, 2011. Receipts for gifts less
                                          q   Please continue my monthly donation until I
                                              tell you to stop.                                          than $25 will be issued by request.

Other Options:
LEADERSHIP RECOGNITION                                      DESIGNATIONS                                      PLANNED GIVING
 Your gift of $500+ distinguishes you                (Optional) A portion of your gift                  q I would like more information on
 as a Leadership Donor and you may                   may be designated to another                          other charitable gift options such
 be publicly recognized. Please print                registered Canadian charity.                          as bequests, life insurance or gifts
 your name as you would like it to                   (Minimum $50 per charity, 5                           of publicly traded securities.
 appear in published materials.                      charities maximum. $12 cost
                                                     recovery fee per designation.)                     q I have included United Way in
 _________________________                                                                                 my will.
                                                     Please complete Gift Distribution
 q I wish to be anonymous.
                                                     section on back.
                                                                    Gift Distribution

u      My gift for United Way to address community priorities $______________
      (United Way will invest in programs and services where the need is greatest)

u      My gift for United Way to address a specific community priority
      (Will fund programs and services in my community)

                        Family & Community Well-being                                                                   $______________

                        Housing for Homeless,
                        Low Income & Working Poor                                                                       $______________

                        Mental Health & Addictions                                                                      $______________

I give permission to inform the following agencies of my gift – please check box if yes.

u      My gift to UVic (UVic would appreciate hearing of your donation)

UVic Programs: (Program Name):_________________________                                                                     $______________                       q
UVic Programs: (Program Name):_________________________                                                                     $______________                       q
u      Other Designations

                        Name of Charity _______________________                                                             $______________                        q
                        Name of Charity _______________________                                                             $______________                        q
                                                            TOTAL GIFT                                                      $______________
                                                            (Should match “My Total Donation” on front)


United Way of Greater Victoria is committed to protecting the privacy and confidentiality of your personal information. Your personal information is used only for United Way’s
and your organization’s campaign; to administer your donation and contact you about renewal; to respond to your information requests; to know who our donors are; to
periodically, as we are able, send you literature on United Way or invite you to recognition events and information sessions; and to thank you and recognize your gift.
To see our complete privacy policy, please go to Charitable Business Number 119278224RR0001
United Way of Greater Victoria • 1144 Fort Street • Victoria BC • V8V 3K8 • Ph 250.385.6708 • F 250.385.6712 •

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