Farmers & Merchants State Bank WORKPLACE PLEDGE FORM Preferred Donation Method Payroll Deduction Check Cash Credit Card / Debit Payroll Deduction - Starts in January 2025 Contribution Amount Per Month $5 $10 $20 $25 $50 Other… $ Number of Pay Periods for Donation One Time 12 pay periods TOTAL: $0 Update Check Donation Amount of Check $ Check Number # Cash Donation Amount of Cash $ Credit / Debit Card Donors: Thank you for your support of United Way of Otter Tail & Wadena Counties. To complete your donation by credit or debit card - please click here. Your Name Title First Middle Last Suffix Your Contact Information Company Email Phone Home Address City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP Code Designation Please select your designation: Please select your designation: - Select -United Way of Otter Tail & Wadena Counties (Fergus Falls)United Way of Becker County (Detroit Lakes)United Way of Bemidji AreaUnited Way of Crookston, Inc.United Way of Douglas and Pope Counties (Alexandria, MN)Jamestown United WayMissouri Slope Areawide United WaySouris Valley United WayUnited Way of Barnes CountyUnited Way of Cass-ClayUnited Way of Grand Forks, East Grand Forks and AreaBrookings Area United WayWatertown Area United WayUnited Way of Northeastern SD, Inc. (Aberdeen, SD)Other... Enter other… Agreement My signature below, confirms my payroll deduction request as stated above. Signature Reset Submit Leave this field blank
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