Authorization ForM

Seekonk Congregational Church UCC680315
Effective date of authorization: ____________________________
Type of Authorization Form:	q New Authorization q Change donation amount q Change donation date			q Change banking information q Discontinue electronic donation
Last Name					First Name
Address
City					State		Zip
Please debit my pledge from my: (check one) q Checking Account (attach a voided check below) q Savings Account (contact your financial institution for Routing #)					Routing Number: _______________________________ Valid Routing # must start with 0, 1, 2, or 3 Account Number: _______________________________
Date of first donation:		Frequency of donation: (check only one)					Church Contribution:
______/______/______		q Weekly – Mondays q Monthly on the 1^st					q Current Expenses q Mission Total			$ ________ $ ________ $ ________
Other Optional Monthly CONTRIBUTION q Deacons Fund: Provides financial assistance to members with special needs at the discretion of pastor and/or deacons. q Debt/Mortgage Reduction: Additional opportunity to assist in paying the church mortgage.			$ __________ $ __________					Monthly on the 1^st Monthly on the 1^st
Agreement I authorize the above church and Vanco Services, LLC 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:________________

Please attach voided check here.