Pledge Form Delta Dental - Capital Area United Way

Invalid Submission Values

This form is for Delta Dental employee payroll deductions.

If you prefer to donate via credit card, after completing the form below, please come back and click here.

Step 1: Donor Information

First Name (required)

Last Name (required)

Mailing Address (required)

City, State, Zip (required)

Phone Number (required)

Email (required)

Example: janedoe@fakeemail.com

Step 2: How Would You Like To Give? (Please complete one of the options below.)

Option A: Payroll Deduction - CHAMP donor - starting January 2023

Check this box if you want to be a CHAMP donor by donating an hour of your pay per month. (2023 salary) If you select this box you can skip down to Step 3.

Keep it simple...make me a CHAMP donor!

I would like my donation

Option B: Payroll Deduction - Specific Amount - starting January 2023

I want to select a specific annual donation amount. This is the total amount I would like for my 2022 pledge. It will be divided by 24 pay periods.

Example: 1,000.50

Option C: Bill Me - begins January 1, 2023

Billling Frequency

Once for the Total

Quarterly

Monthly

My total pledge amount

Example: 1,000.50

Please start my billing cycle

Example: ##/##/####

Step 3: Pledge Acknowledgment & Confirmation

Are you an Evergreen giver? By checking the box below, I acknowledge that I want my gift to renew automatically each year. (required)

Yes please automatically renew my gift annually.

No I would like to manually submit my gift annually.

Are you a CHAMP giver? (You are pledging to donate at least an hour of your pay, each month, to CAUW.) (required)

Yes

Are you a LEADERSHIP Giver? (May be combined with your spouse) (required)

$500+

$1000+

No (less than $500 pledge)

For LEADERSHIP Giving, please combine my gift with my spouse. (List spouse and their employer.)

I would like my thank you to be sent via(required)

I wish my gift to remain anonymous. (Please note: If you choose this option, you will not show up on any listings, even if you are a CHAMP or LEADERSHIP Giver.) (required)

Yes

Signature (required)