Authorization Agreement for Pre-Authorized Drafts

I (we) hereby authorized The Church of the Good Shepherd , herein after called COMPANY, to initiate debit entries to my (our) ( Names(s):__________________  ) Checking Account  or Savings Account (Select one) indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account.  I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with provisions of U.S. law.

Monthly Option:

I Authorize $_________ to be drafted from my account on the 1^st of each month or $__________on the 15^th of each month (choose one).  With this option you are paying once a month. 

Twice Monthly Option:

I authorize $__________ to be drafted from my account on the 1^st of each month and $__________ on the 15^th of each month.

Depository

Name _______________________________________________

BRANCH______________________________  ACCOUNT TYPE (Savings/Checking)

CITY__________________________________     STATE________ZIP_________

TRANSIT/ABA NO. __________________                        ACCOUNT NO.______________

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

NAME(S)_________________________                PHONE_________________

                        (PLEASE PRINT)

SIGNED__________________________                DATE___________________

SIGNED__________________________                DATE___________________