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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 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.



Signature ______________________





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