United Way Pledge Form NAME AND CONTACT INFORMATION FIRST NAME: MI _ LAST NAME: HOME ADDRESS: _ CITY: _ STATE: ZIP: _ HOME PHONE: _ DAYTIME PHONE: _ E-MAIL: GWID: EMPLOYER: THE GEORGE WASHINGTON UNIVERSITY YOUR CONTRIBUTION Your contribution is your monthly agency fee, which will be determined by SEIU Local 500 and deducted per pay period by GWU Payroll CHOOSE ONE OPTION FROM THE FOLLOWING SELECTIONS SEE UNITED WAY’S WEBSITE FOR CONTRIBUTION OPTIONS HTTPS://UNITEDWAYNCA.ORG/GET-INVOLVED/DONATE/ Option A - CONTRIBUTE TO UNITED WAY OF THE NATIONAL CAPITAL AREA (UWNCA) Your contribution will be used by the Board of Directors to advance the UWNCA mission Option B - CONTRIBUTE TO UNITED WAY’S SPECIAL COMMUNITY INITIATIVES Your contribution will help solve three of the Greater Washington area’s most critical issues 9072 9073 9074 Education Fund Financial Stability Fund Health Fund Option C - CONTRIBUTE TO UNITED WAY’S COMMUNITY IMPACT FUNDS Your contributions will fund grants to agency programs as selected by community volunteers You may choose to fund the programs for the entire Capital area, or to an individual region 9000 9001 9002 9003 9004 National Capital Area Community Impact Fund Alexandria Community Impact Fund Arlington Community Impact Fund District of Columbia Community Impact Fund Fairfax-Falls Church Community Impact Fund Option D - CONTRIBUTE 9005 9006 9007 9008 Loudoun Community Impact Fund Montgomery Community Impact Fund Prince George’s Community Impact Fund Prince William Community Impact Fund [UW] TO A SPECIFIC AGENCY Please include the COMPLETE agency address to ensure accurate processing United Way of the National Capital Area Agency AGENCY NAME _ DIRECTORY CODE _ Other health and human service agency, or other United Way AGENCY NAME _ DIRECTORY CODE ADDRESS _CITY _STATE _ ZIP SIGN HERE TO AUTHORIZE PLEDGE AND PAYROLL DEDUCTION I agree that if my designation is to an agency that is not an IRS-recognized 501 (c) (3) or is not in compliance with the United States Patriot Act, then my donation will be directed to the UWNCA Community Impact Fund I agree that any portion of my pledge that is not fully designated will be directed to the UWNCA Community Impact Fund I agree that if for any reason my donation is unclaimed by the designated agency, my donation will be directed to the UWNCA Community Impact Fund Please check here if you prefer that your gift remain anonymous _ Signature Date Please sign and forward to GW Faculty Personnel at 2121 Eye Street, NW, Suite 813, Washington, DC 20052 or via fax (202) 994-5375 For any questions, please contact us at (202) 994-6783 or facpers@gwu.edu Rev May 2018