Monthly donor authorization form

Springfield Education Foundation

Date: ____________________________________________

 Name: ___________________________________________

For:     Authorization Agreements for Monthly Donations 

 

I authorize the Springfield Education Foundation to initiate debit entries of my

checking or savings account (please select below) to Umpqua Bank. I (we) acknowledge that the origination of these transactions to my account must comply with the provision of the US law.

 

I would like the donation of $_______ a month to be taken from my (check one):

____ Checking Account # ____________________

____ Savings Account # _____________________

 

My voided check is attached.

 

I would like my donation to be taken out on (please check one):

____ The first of each month

____ The 15^th of each month

 

This authorization is to remain in effect until the Springfield Education Foundation has received written notification from me to terminate.  I will allow for sufficient time for the Springfield Education Foundation a reasonable opportunity to stop payments.

 

I am aware to change the date, amount or skip a monthly donation I will contact the Springfield Education Foundation five working days before the scheduled entry date.

 

 

Signature ______________________