Midwest Regional ESC United Way Pledge Form
RequiredRequired Question(s)
Required 1.
YES!  I will join the fight for the health, education, and financial stability of all in my community.  I will make the following payroll deduction pledge.  (To make a cash, check, or credit card gift, scroll to the bottom of the form for instructions.)
$25 / pay
$10 / pay
$5 / pay
$2.50 / pay
Other  
Required 2.
Your number of pay periods/year.
 

50 characters left.
Required 3.

To which county United Way would you like to direct your gift?

United Way of Hardin County
United Way of Logan County
Shelby County United Way
Other  
4.
OPTIONAL:  Do you wish to designate your gift to a specific United Way agency or program in that county?  If so, type the name of the agency below.  For a directory of United Way-supported programs in your county, click the links below.

United Way of Hardin County
United Way of Logan County
Shelby County United Way  (Minimum $25 donation for Shelby County agency designation.)
 

50 characters left.
Required 5.
Please enter the information indicated below.

First Name:
Last Name:
Email Address:
emailaddress@xyz.com
Address 1:
City:
Postal Code:

CREDIT CARD
If you wish to make a gift via credit card, please click here.

CASH / CHECK
If you wish to make a one-time cash or check donation, please print (Control-P or right-click and print) and complete this form and send it with your donation to the one of your ESC United Way contacts:

AMY SIMINDINGER at 129 E. Court St., Sidney, OH 45365
KAREN SORRELES at 1973 St Rt. 47 W.,  Bellefontaine, OH, 43311