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Payment Authorization Form
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Church, School, or Diocese Name
OUR LADY OF GOOD COUNSEL, ENDICOTT,NY |
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Name on account (Print) |
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Account Holder`s Phone # |
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Address
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City, State, and Zip
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I authorize the following: |
r New Payment from Account Specified Below
(Choose either bank or credit card. One account only, please.)
r Change Indicated Below
r Discontinue Electronic Funds Transfer from Account or Fund Specified Below. |
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Account Information
(Choose either Bank or Credit Card. Provide information below for one account only.) |
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Bank Account Information |
Credit Card Information |
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Bank Name |
Credit Card Type
r Mastercard
r Visa |
r American Express
r Discover
r Other (provide type below)
__________________________ |
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Account Type |
r Checking (please attach voided check)
r Savings (please attach deposit slip) |
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Routing Number
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Credit Card # |
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Account Number
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Credit Card Expiration Date |
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Authorization Effective Date / / |
Authorization Effective Date / / |
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Contribution Schedule |
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Fund Type
(e.g., Sunday Offering,DSA Pledge, etc.) |
Payment Schedule |
Amount |
Payment
Start Date |
Collection Date (Choose date for withdrawal from your account)) |
Down Payment
(if applicable) |
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r Monthly
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$ |
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r 10th |
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$ |
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r Monthly
r Quarterly |
r Semi-annually (2x/year)
r One Time |
$ |
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r 1st
r 5th
r 10th |
r 15th
r 20th
r 25th
r None |
$ |
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r Monthly
r Quarterly |
r Semi-annually (2x/year)
r One Time |
$ |
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r 1st
r 5th
r 10th |
r 15th
r 20th
r 25th
r None |
$ |
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r Monthly
r Quarterly |
r Semi-annually (2x/year)
r One Time |
$ |
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r 1st
r 5th
r 10th |
r 15th
r 20th
r 25th
r None |
$ |
I authorize the above-named church or school to debit from the account specified on this form. This authorization will remain in effect until I give reasonable change or cancellation notice to terminate authorization. I understand there will be a $_______ nonsufficient funds (NSF) fee charged to my account for NSF debits.
Authorized account signature:____________________________________________________ Date:_________________
For checking or savings account debits, please attach your voided check or savings deposit slip
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