Mary Queen Parish – 2016 Stewardship of Treasure Donation
ACH/EFT Preauthorized Payment Authorization Agreement
Thank you for allowing Mary Queen Parish to offer this time-saving, efficient means of making your 2016 Stewardship of Treasure donations. Completion of this form will allow Mary Queen Parish to automatically debit the authorized checking/savings account you provide below. Please complete this form in its entirety.
Name(s) (Please print): ____________________________________________________
Mailing Address: __________________________________________________________
E-mail Address: __________________________________________________________
I (we) hereby authorize Mary Queen Parish to initiate debit entries to the account listed below. I understand that, if necessary, credit entries and adjustments for any debit entry in error may be made to my account in relation to such debit entries.
This authorization will remain in effect until Mary Queen Parish has received written notification from me at least 30 days prior to the next scheduled debit date.
Signature(s) ________________________ _____________________________
Name on Account: _________________________________________________________
Financial Institution Name: __________________________________________________
Financial Institution ABA/Routing Transit Number: __ __ __ __ __ __ __ __ __
(Note: Usually these are the first nine digits on the bottom of check.)
Individual Account Number: ________________________________________________
This account is a _____checking account, _____ savings account (select one).
Payment Frequency: Please select only one option.
________ Monthly (Account will be debited by the 10th of each month.)
________ Weekly (Account will be debited each Monday.)
Amount Authorized: _________________
Date to begin the Debit: _________________
Please affix a voided check in the space provided below so that we may confirm your bank and account information. By executing this document, you are agreeing to hold harmless Mary Queen of the Holy Rosary Parish from any overdrafts that may occur as a result of this debit to the account. In no event shall Mary Queen of the Holy Rosary Parish be liable for any consequential, special, punitive or indirect loss or damage you may incur or suffer in connection with this transaction.
Please submit this form to the parish office, ATTN: Walter Leachman, Business Manager.
Attach Voided Check Here.
No Deposit Tickets.
last updated 11/11/2015 jm
