United Church of Church UCC300830
Authorization Agreement for Automatic Withdrawal of Funds
Envelope # _________________ (leave blank if not applicable)
Name on Bank Account (please print) __________________________________________________
Address _____________________________________________________________________________
City _____________________________________ State ___________________ ZIP _________
Please debit my contributions from my (check one):
oChecking Account (attach voided check) Routing Number: __________________________
oSavings Account (attach savings deposit slip) (Routing # is located at bottom of check between the symbols l: l:)
Account Number: __________________________
Regular Contribution
I would like to make the following contribution(s):
o Regular pledge $_________________
o Capital Campaign $ ________________
Contribution Frequency (please check one):
o Weekly - Debited on Mondays
o Semimonthly - Debited on the 5th and the 20th
o Monthly - Debited on the 5th or the 20th (please circle one)
Please make my ongoing contribution effective ___________________________ (date of 1st contribution)
I authorize Central Square Congregational Church, UCC and Vanco Services, LLC to process debit entries from my account. This authority will remain in effect until I give reasonable notification to terminate this authorization. I understand there will be a $5.00 fee automatically charge to my account for any insufficient fund (NSF) transactions. I have attached a voided check or savings deposit slip below.
Signed: ____________________________________________________ Date: ___________________
Please place a voided check or savings deposit slip here
