Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.General InformationYour Name *FirstLastAuthorization Date Today's DatePersonal or Business Account? *Personal AccountBusiness AccountBusiness NameIf applicableAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Banking & Donation InformationFinancial Institution Name *Routing Number (9 digits) *Account Number *Checking or Savings Account? (allow 2 weeks for us to verify account & process your donation) *--- Select Choice ---Checking AccountSavings AccountOne time or recurring donation?-Choose One *--- Select Choice ---One time contributionRecurring contribution time 2 first Monthly recurring donation amount5.0010.0015.0020.0025.0030.0035.0040.0045.0050.0055.0060.0065.0070.0080.0090.00100.00125.00150.00175.00200.00250.00300.00350.00400.00500.00600.00700.00800.00900.001000.00Choose amount for monthly recurring donation. Enter your own monthly donation amount not offered in the drop down above?NoYesTo select your own monthly donation amount that is not offered in the "Monthly recurring" options in the drop down above-Select Yes, and a new text box will appear to enter your custom dollar amount. Enter custom monthly donation amount here. Use two decimals and commas as applicable. Ex ($1,100.00)Recurring Donation Date1st5th15th20th30thOne time donation amount *Enter dollar amount of one time donation. This authorization will remain in effect until it is terminated and instructions changing the payment are received. Revocation may be orally by calling 608-478-4465 or by emailing cathy.redders@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 agreeI do not agreeDo not proceed if you do not agreeAuthorization-Type first and last name in below box to agree SFTSM to electronically debit your account. *Submit
