Monthly donor authorization form
Springfield Education Foundation
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 15th 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.