1 Start 2 Complete Preferred Donation Method Options - Select One * Payroll Deduction Check Cash Bill Me Credit Card or ACH Amount Per Pay Period * Frequency you are Paid * - Select -Weekly (52 times/yr)Bi-Weekly (26 times/yr)Semi-Monthly (24 times/yr)Other Please indicate how often you are paid: If other, what frequency: Amount of Check * Make checks payable to: United Way of Northeast Kentucky Payment Frequency Onetime Monthly Quarterly Semi-Annually Other If other, what frequency: Amount of Cash * Payment Frequency Onetime Monthly Quarterly Semi-Annually Other If other, what frequency: Amount per Invoice * Frequency of Billing * Monthly Quarterly Semi-Annually Annually Date of First Billing * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022 If donating by credit card or ACH, please CLICK HERE to exit this form and complete your online transaction. My Contact Information Title - None -Mr.Mrs.Ms.Dr. First Name * Middle Initial Last Name * Home Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Email Address * Phone * Employer Information Employer * - Select -Ashland Community & Technical CollegeAmerican Electric Power/Kentucky PowerAir ProductsAK SteelAshland Independent SchoolsAshland Credit UnionAT&TBoyd County SchoolsCalgon CarbonCarter County SchoolsCity National BankCity of AshlandClarks Pump N ShopCoca Cola CoCommercial Bank of GraysonCommunity HospiceElliott County SchoolsFairview Independent SchoolsFifth Third BankFirst & Peoples Bank & Trust Co,First National Bank of GraysonGeneral Sales CompanyGreenup County SchoolsGriffith Delaney Hillman & LettHuntington Alloys CorporationJCPenneyKing's Daughters Medical CenterKelley Galloway Smith GoolsbyKentucky Farmers BankKrogerLawrence County SchoolsLouisville Gas & Electric / Kentucky Utilities CompanyMarathon Petr oleum CorporationMembers Choice Credit UnionMiddough ConsultingO'Reilly Auto PartsPathwaysPeoples BankRaceland-Worthington Independent SchoolsRaymond JamesRussell Independent SchoolsSafe HarborSelf EmployedSmithfield FoodsSWVA Kentucky LLCThree Rivers Medical CenterTRC Global MobilityTri State India AssociationTurner Industries GroupUPSUS BankWalbridgeWalmartOther Department: Other Employer My Impact (Optional) Select all that apply: Community Impact Fund - All Programs Education Financial Stability Health Another United Way (minimum $52 pledge to use this option) A UWNEK approved community Partner Agency (minimum $52 pledge to use this option) Note: Designations may only be made to nonprofit organizations holding a tax-exempt status from the Internal Revenue Service providing health and human service programs to residents of Boyd, Carter, Elliott, Greenup, and Lawrence counties. This includes all United Ways and national organizations that serve the same residents listed above. The minimum contribution that can be designated is a contribution of $52. United Way of Northeast Kentucky puts great effort into fulfilling the wishes of our donors. Designations with incomplete or inaccurate information will be disbursed through the Community Investment process. Other United Way Name Donation Details For designations, Please use the codes listed above and detail your designation below. I am interested in: I am interested in: Volunteer opportunities Community Investment panel member opportunity Verification I verify that I have made the pledge above to the United Way of Northeast Kentucky for the 2020-2021 campaign and authorize deductions or payments as indicated on this form * Type your name in the above box.