United Way

United Way of Oxford-Lafayette County Logo

First Name

Last Name

Mobile Number

Address

City

State

Zip

I would like $______________ deducted

for _______ pay periods

Total Payroll Deduction

$0.00

Cash/Check/Other: $__________

Bank Draft (Total Pledge): $__________

Bank Draft Frequency

Total Direct Gift

$0.00

I have been donating to United Way approximately ____ year(s).

Please check if this is your first gift to United Way.

Please check if you are 35 or younger.

Name(s) in UW Materials

I/We prefer to be anonymous.