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Kocolene: JCUW Annual Campaign 2021-2022

Online Giving

First Name *

Last Name *

Phone *

Please include an email address for an emailed receipt.

Birth Date

Street Address

City

State

Postal Code

Leadership Giving

Booster $1,000

Merit $1,500

Pacesetter $3,000

Jackson Society $5,000

National Tocqueville Society $10,000+

Please choose the amount per pay period you would like to give to help the community!

I want to contribute the following amount per pay period *

$5
$10
$15
$25
$50
Fair Share (one hour's pay per month)
Same Donation Amount Last Year
Other

Pay Periods *

Weekly (52 payments)

Biweekly (26 payments)

Monthly (12 payments)

If you have selected fair share (one hours pay per month) please list your hourly pay.

Fair Share Amount

Other Amount

Please write anything you would like United Way to know about your gift.

Notes

If you would like to give a one time donation with a debt/credit card, please include the card number, expiration date, and code on the back.

Credit Card Information

Electronic Signature

PO Box 94
113 N Chestnut, Ste 305
Seymour, IN 47274
812-522-5450