authorization form

I authorize the above organization to process debit entries to my account. I understand that this authority will remain in effect until I provide reas...

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AUTHORIZATION FORM Name of the organization: ______________________________________ FOR OFFICE USE ONLY

ENVELOPE/DONOR #

DATE

Effective date of authorization: _____/_____/_____ Type of authorization:

 

 

New authorization Change banking information

Last Name



Change donation amount Discontinue electronic donation

Change donation date

First Name

Address City

State

Zip

Email Address DATE OF FIRST DONATION: _______/_______/_______

FREQUENCY OF DONATION:

   

Weekly – Mondays st

th

Semi-Monthly – 1 and 15 Monthly on the 1st

FUNDS:

  

AMOUNTS:

General/Operating

$_____________

Building

$_____________

____________________

$_____________

th

Monthly on the 15

Total

CHECKING / SAVINGS

Please debit my donation from my (check one):



Savings Account (contact your financial institution for Routing #)



Checking Account (attach a voided check below)

$_____________

Routing Number: ____________________________ Valid Routing # must start with 0, 1, 2, or 3 Account Number: ____________________________

I authorize the above organization to process debit entries to my account. I understand that this authority will remain in effect until I provide reasonable notification to terminate the authorization. Authorized Signature:_______________________________________________________ Date:________________

If using a checking account, please attach a voided check at the bottom of this page.

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