Thank you for supporting the United Way Campaign! WORKPLACE PLEDGE CARD Preferred Donation Method Payroll Deduction or PTO Check or Cash Credit Card / ACH Payroll Deduction or PTO Payroll Deduction or PTO $5 $10 $20 $25 $50 Other… $ Number of Pay Periods 1 time 10 pay periods 12 pay periods 24 pay periods 26 pay periods Other Enter the Number of Pay Periods TOTAL TOTAL ANNUAL PAYROLL DEDUCTION: $0 Update NOTE: Payroll deductions for this donation will begin January 2023. # of PTO hours. Cash or Check Donation To donate by cash or check, please print this form and drop off to your supervisor or campaign ambassador. You can also mail to United Way of Clallam County, PO Box 937, Port Angeles, WA 98362. Amount of Cash or Check (make checks payable to United Way of Clallam County) $5 $10 $20 $25 $50 Other… $ If donating by credit card or ACH, please CLICK HERE to exit this form and complete your online transaction. 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Save postage. Don’t send me a thank you letter. Don’t release my name to agencies I designate. PLEASE DISTRIBUTE MY GIFT AS FOLLOWS Please ensure your distributions equal the total contribution you listed above Distributions not designated below will be allocated to the United Way Community Fund. Designation Options United Way Community Fund COVID-19 Relief Fund American Red Cross Northwest Region - South Puget Sound and Olympics Boys & Girls Clubs of the Olympic Peninsula Camp Beausite Northwest Catholic Community Services of Western Washington (CCSWW) Clallam-Jefferson County Pro Bono Lawyers Clallam Mosaic Clallam Resilience Project Concerned Citizens Dolly Parton's Imagination Library First Step Family Support Center Forks Community Food Bank Habitat for Humanity of Clallam County (HFHCC) Healthy Families of Clallam County Lutheran Community Services Northwest Mariposa House North Olympic Regional Veteran’s Housing Network (NORVHN) Olympic Community Action Programs Olympic Peninsula YMCA Peninsula Behavioral Health Peninsula Dispute Resolution Center Serenity House of Clallam County Society of St. Vincent de Paul - St. Joseph Conference St. Andrew's Place The Dungeness Valley Health & Wellness Clinic (Sequim Free Clinic) West End Youth & Community Club Other Amount to United Way Community Fund $ Amount to American Red Cross Northwest Region - South Puget Sound and Olympics $ Amount to Boys & Girls Clubs of the Olympic Peninsula $ Amount to Camp Beausite Northwest $ Amount to Catholic Community Services of Western Washington (CCSWW) $ Amount to Clallam-Jefferson County Pro Bono Lawyers $ Amount to Clallam Mosaic $ Amount to Concerned Citizens $ Amount to the Dolly Parton Imagination Library $ Amount to First Step Family Support Center $ Amount to Forks Community Food Bank $ Amount to Habitat for Humanity of Clallam County (HFHCC) $ Amount to Healthy Families of Clallam County $ Amount to Lutheran Community Services Northwest $ Amount to Olympic Community Action Programs $ Amount to Mariposa House $ Amount to North Olympic Regional Veteran’s Housing Network (NORVHN) $ Amount to Olympic Peninsula YMCA $ Amount to Peninsula Behavioral Health $ Amount to Peninsula Dispute Resolution Center $ Amount to Serenity House of Clallam County $ Amount to Society of St. Vincent de Paul - St. Joseph Conference $ Amount to St. Andrew's Place $ Amount to The Dungeness Valley Health & Wellness Clinic (Sequim Free Clinic) $ Amount to West End Youth & Community Club $ Other Non-Profit Amount to Other $ Leadership Giving - $250 or More United Way of Clallam County has a recognition program for individuals and couples who donate $250 or more to United Way and Partner Agencies. 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