1. My InformationYour personal information is never shared.Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Middle Initial Last EmployerAddress* Home Mailing Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Email PhoneDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119202. My InvestmentPayment Type*Payroll deduction at my employerPay now with a credit/debit cardBill meBilling FrequencyOne TimeMonthlyQuarterlyPayroll Deduction OptionsPlease choose only one. The first four options entitle you to a United Way t-shirt. Please indicate your size in the appropriate box. Fair Share: 1 hour's pay per month Average Gift: $3.75 per week Leadership Gift: $10 per week Pillar Society: $20 per week Other Gift Fair Share: My Hourly Rate is*Other Gift Amount*Enter the amount you would like deducted per pay period.T-Shirt SizeFair Share, Average Gift, and above receive a t-shirt.SMLXL2X3X4XNo, thank you.3. My ImpactChoose where your gift is applied: United Way Community Care Fund: Use my gift where it's most needed. Academic Success Health & Wellness Family Stability Specific United Way partner organization Another United Way Choose the United Way partner organization*4-H Itawamba County4-H Lee County4-H Prentiss County4-H Tishomingo CountyAgape Health Services, Inc.American Red Cross, North Mississippi ChapterAssociation for Excellence in Education (AEE)Autism Center of North MississippiBackpack Ministry of Tishomingo CountyBanah Pregnancy Testing Center of Pontotoc, Inc.Big Brothers/Big Sisters of Northeast MississippiBoy Scouts Yocona Area CouncilBoys & Girls Clubs of North MississippiBoys & Girls Clubs of Northeast Mississippi - Baldwyn ClubBoys & Girls Clubs of Northeast Mississippi - Booneville ClubBoys & Girls Clubs of Northeast Mississippi - Iuka ClubCATCH KidsChurch After School Association, Inc. (CASA)El Centro, Inc.EXCEL, Inc.ExPectF.A.I.T.H. Food PantryFaith Haven, Inc.Family Resource Center of North MississippiFellowship of Christian AthletesFood Depot of Tishomingo CountyFuller Center for Housing of Houston, MS, Inc.Fulton United Methodist Food PantryGirl Scouts Heart of the SouthGood Samaritan Center of Union CountyGood Samaritan Health Services, Inc.Habitat for Humanity of Northeast MississippiHabitat for Humanity of Pontotoc CountyHelpful Samaritan Food PantryHope Family Ministries, Inc.Itawamba United Methodist Food Pantry WestMeals on Wheels, MSMSSMission OkolonaNational Council on Alcoholism and Drug Dependence of NEMS, Inc.New Haven Center for Special Needs AdultsNMMC Camp BluebirdNMMC Diabetes Treatment Center Patient Assistance FundNMMC Heart & Vascular Institute Patient Assistance FundNMMC Hospice Patient Assistance FundNMMC Social Work Patient Assistance FundNorth MS Kidney FoundationParkgate Pregnancy Clinic, Inc.Regional Rehabilitation Center, Inc.S.A.F.E., Inc.Saints' BrewSally Kate Winters Family ServicesSalvation ArmySalvation Army - Chickasaw CountySalvation Army - Pontotoc CountySanctuary Hospice House, Inc.Shepherd's Center of Greater TupeloSpecial Education Bowling AssociationSt. Luke United Methodist Food PantryTalbot House, Inc.The Sunday Fund at TracewayThree Rivers Area Agency on AgingWeekend Backpack ProgramWhich other United Way?*List a United Way name, county, or city. 4. My RecognitionPlease link my gift to my spouse/partner.Spouse NameSpouse Employer Please send me information about Groundswell (under 40) Please send me information Women United (women's leadership) I plan to retire within the next two years. I would like to remain anonymous.