The “500” Club

 AUTHORIZATION FORM

 

FOR OFFICE USE ONLY

DONOR  Name

DATE

 

 

           Type Of Authorization                    Effective date of authorization            /          /               

o     New Authorization              

o    Change banking information

o    Change donation amount                                                                

o    Change donation date

o    Discontinue electronic donation

Last Name

First Name

Address

City

State

Zip

Email Address

 

Please debit my donation from my (check one):

o    Checking Account (attach a voided check below)

o    Savings Account (contact your financial institution for Routing #)

 

Routing Number:          211170282  

Valid Routing # must start with 0, 1, 2, or 3

 

Account Number:         6574288221

FIRST DONATION DATE:

 

           _/           _/         

FREQUENCY OF DONATION:

o    Monthly         on                              

o    Semi-Monthly

(transferred on 1st and 15th of each month)

 

 

AMOUNT             $                    

 

AGREEMENT

I authorize Ray of Light Farm, Inc and Liberty Bank 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:                                      

 

 

 

For those who do not bank at Liberty Bank, fill out this form for your bank and give it to them with your check or submit online.
 
                 Please attach voided check here.