Contribution Form

Please complete the following information to make a donation to the United Way of Portage County.

Personal Information

Title:

City:

First Name:

State:

Last Name:

Zip:

Street Address:

Phone

Email:

Donation Information

Gift Amount:

$25

$250

Donations of $500 - or more, are recognized as leadership giving levels. Additional information will be sent if you donate at this level.

$50

$500

$75

$1000

$100

Other Amount (please specify)

Payment Method:

Mailing check or cash

Please bill me before year-end '06

Please bill me quarterly, beginning January '07

Please bill me monthly, beginning January '07

Please bill me one billing, (month) '07

Please call me regarding credit card payment or automatic funds withdrawal.

To contribute to a United Way other than Portage County, please indicate the name:

No administrative fee is charged for processing any pledges.