Designation Form
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United Way of Southwest Michigan No item of material value has been exchanged for this pledge. SMLSCC #3083
Designation Form
$100 minimum per choice. Please do not designate dollars in excess of your total gift. This designation form must be attached to a copy of the individual’s pledge form. If a pledge was made electronically, please fill out Pledge Amount/Method of Payment section below.
1
My Information (Please Print Clearly)
First Name:
MI:
Last Name:
State:
Zip:
Home Address: City: Company:
2
Pledge Amount & Method of Payment
My total Gift is: $_________ Payroll Deduction
3
Bill Direct
Credit Card
Cash/Check
Influencing the Condition of All
Community Impact Fund: Designating to Community Impact is the most effective way to improve people’s lives and create sustained changes in community conditions. United Way is your partner, using unrestricted dollars, along with its professional and volunteer expertise, to create measurable community impact. % Total Gift: $ or $_______ or_______%
$_______ or________%
$_______ or________%
$_______ or_______%
Education
Income
Health
Basic Needs
Specific Impact Agency Code_________________$__________or____________% Agency Code_________________$__________or____________% SPECIFIC IMPACT If you wish to direct your gift to a specific UW partner agency, where a program is being funded, indicate the code number on this form. 1001 1041 1023 1003 1027 1026 1030 1005 1050 1029 1020 1032 1008 8008 1010 1043 1012 1051
American Red Cross of Southwest Michigan Andrews University Benton Harbor-St. Joseph YMCA Berrien County Cancer Service Berrien County Council for Children Berrien County Health Department Berrien Regional Education Service Agency (RESA) Big Brothers Big Sisters of Berrien & Cass Boy Scouts of America, Lasalle Council Boys & Girls Club of Benton Harbor Centered on Wellness Community AIDS Resource & Educ. Serv. (CARES) Child & Family Services of Southwestern Michigan Domestic and Sexual Abuse Services (DASAS) Emergency Shelter Services Feeding America West Michigan Food Bank Gateway Girls on the Run of Southwest Michigan
1035 1040 1031 8023 1044 1024 1045 1042 1011 1021 1018 1019 1047 8016
Harbor Habitat for Humanity Heartland Human Care Services Kinexus Lewis Cass ISD Logan Community Resources, Inc. Niles Buchanan YMCA Mosaic CCDA MI-Journey Region IV Area Agency on Aging Senior Nutrition Services, Region IV The Salvation Army, Benton Harbor Corps The Salvation Army, Niles Corps Well of Grace Woodlands Behavioral Healthcare Network
NEIGHBORING UNITED WAYS 3001 Allegan County, MI 3007 Kalamazoo and Battle Creek, MI 3003 Greater LaPorte County, IN 3005 St. Joseph County, IN 3006 Van Buren County, MI If your community is not listed, please use the zip code as the agency code.
_%
_____%
ps
ork
United Way of Southwest Michigan No item of material value has been exchanged for this pledge. SMLSCC #3083
Designation Form
$100 minimum per choice. Please do not designate dollars in excess of your total gift. This designation form must be attached to a copy of the individual’s pledge form. If a pledge was made electronically, please fill out Pledge Amount/Method of Payment section below.
1
My Information (Please Print Clearly)
First Name:
MI:
Last Name:
State:
Zip:
Home Address: City: Company:
2
Pledge Amount & Method of Payment
My total Gift is: $_________ Payroll Deduction
3
Bill Direct
Credit Card
Cash/Check
Influencing the Condition of All
Community Impact Fund: Designating to Community Impact is the most effective way to improve people’s lives and create sustained changes in community conditions. United Way is your partner, using unrestricted dollars, along with its professional and volunteer expertise, to create measurable community impact. % Total Gift: $ or $_______ or_______%
$_______ or________%
$_______ or________%
$_______ or_______%
Education
Income
Health
Basic Needs
Specific Impact Agency Code_________________$__________or____________% Agency Code_________________$__________or____________% SPECIFIC IMPACT If you wish to direct your gift to a specific UW partner agency, where a program is being funded, indicate the code number on this form. 1001 1041 1023 1003 1027 1026 1030 1005 1050 1029 1020 1032 1008 8008 1010 1043 1012 1051
American Red Cross of Southwest Michigan Andrews University Benton Harbor-St. Joseph YMCA Berrien County Cancer Service Berrien County Council for Children Berrien County Health Department Berrien Regional Education Service Agency (RESA) Big Brothers Big Sisters of Berrien & Cass Boy Scouts of America, Lasalle Council Boys & Girls Club of Benton Harbor Centered on Wellness Community AIDS Resource & Educ. Serv. (CARES) Child & Family Services of Southwestern Michigan Domestic and Sexual Abuse Services (DASAS) Emergency Shelter Services Feeding America West Michigan Food Bank Gateway Girls on the Run of Southwest Michigan
1035 1040 1031 8023 1044 1024 1045 1042 1011 1021 1018 1019 1047 8016
Harbor Habitat for Humanity Heartland Human Care Services Kinexus Lewis Cass ISD Logan Community Resources, Inc. Niles Buchanan YMCA Mosaic CCDA MI-Journey Region IV Area Agency on Aging Senior Nutrition Services, Region IV The Salvation Army, Benton Harbor Corps The Salvation Army, Niles Corps Well of Grace Woodlands Behavioral Healthcare Network
NEIGHBORING UNITED WAYS 3001 Allegan County, MI 3007 Kalamazoo and Battle Creek, MI 3003 Greater LaPorte County, IN 3005 St. Joseph County, IN 3006 Van Buren County, MI If your community is not listed, please use the zip code as the agency code.
