Thank you for your support – “Live United”

Blackford United Way, Inc., PO Box 67, Hartford City, IN 47348

Name

Address

Phone # E-mail

Total Pledge Enclosed $

$ donated to specific agency (list agency):

I hereby request that the funds designated herein be remitted to the above named agency as first money in on said agency’s Blackford United Way allocation.

Signature

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If your pledge will be paid by payroll deduction, please completed the following and give a copy to your employer:

Company Name

Total Pledge $

$ per pay for pay periods

I hereby request that the funds designated herein be remitted to the above named agency as first money in on said agency’s Blackford United Way allocation.

Signature

Please mail completed form and donation to

Blackford United Way, Inc, PO Box 67, Hartford City, IN