Benefit Pledge Form Print blank form to mail in. Name* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Email* two ways to giveMY SINGLE GIFT IS Select a payment option: Check will be mailed Contact me about a special gift (i.e. stocks) MY ONGOING MONTHLY GIFT IS: Select a payment option: ACH from Checking (I will mail voided check or contact Nancy, bookkeeper, with account information) I will mail my monthly check I already have an ongoing monthly pledge: Continue my current pledge of: Change the amount of my current pledge to Current or Change Pledge Amount Please include any questions or special circumstances you want to bring to the attention of our bookkeeper.Please include any questions or special circumstances you want to bring to the attention of our bookkeeper. Monthly Authorization:* Monthly Authorization:Please transfer my monthly gift from my account on the 15th of each month (beginning with October 15, 2020) until further notice from me. I understand this agreement is the same as signing a check each month, and I may change it at any time by contacting Little Way.