Authorization Agreement for Checking or Savings Account ACH Debits

I (we) hereby authorize Shelter from the Storm Ministries, Inc. (SFTSM), to debit entries to my (our) account indicated below at the depository financial institution named below, hereinafter called Financial Institution, and to DEBIT the amount listed below to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Checking or Savings Account? (Please allow 5 to 7 business days for us to verify your account & process your donation)

Personal or Business Account?

Business Name

Financial Institution

City

State

Zip Code

Routing Number

Account Number

Choose One

One Time Contribution
Recurring Monthly Contribution

On this day of each month.

Enter the date you would like your payment withdrawn from your account each month.

Recurring payments will need 5-7 business days for the first transaction to pull. SFTSM will pull the payment monthly on the day you specified above. If the payment date falls on a non-business day or holiday it will be pulled the following business day. This authorization is to remain in full force and effect until SFTSM has received written notification from me (or either of us) of its termination in such time and in such manner as to afford SFTSM and Financial Institution a reasonable opportunity to act on it. For your records, please save an electronic or paper copy of this authorization.

I agree

Shelter From the Storm Ministries, Inc. is hereby authorized to debit my account $

Enter the amount of payment.

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Signature

Clear Signature

Today's Date

This authorization will remain in effect until it is terminated and instructions changing the payment method are received. Revocation may be orally by calling 608-516-8023 or by emailing: michelle.hanley@sftsm.org. Notification must be at least 14 business days prior to the scheduled transfer. Please retain a hard or electronic copy of this agreement for your records

I agree

Email