Authorization Agreement for Direct Payments (ACH Debits)

Company Name:   St. Therese Church

Company ID Number:  440660198

• I (we) hereby authorize St. Therese Church, hereinafter called COMPANY, to initiate debit entries to my (our)   

•  □ Checking Account               □ Savings Account (check 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 the provisions of U.S. law.

Depository Name: ____________________________________ Branch: _______________________

City: _____________________________________ State: _____________Zip:_________

Monthly Contribution:  ____________________

Routing Number: _________________________

Account Number: ________________________

Effective Date:  ___________________________(1^st of month as long as request is received in the Parish office 5 days prior to the end of the preceding month)

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.

Please Print:

Name (s): _________________________________  Church Envelope Number: __________________

Date: _____________________ Signature(s): ____________________________________________

You must return this form to the Parish office for your deductions to become effective.

ATTACH VOID CHECK OR BLANK DEPOSIT SLIP.

NOTE: DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.