Download Electronic Contribution Form

Authorization Agreement for Direct Payments (ACH DEBITS)
I (we) hereby authorize St. Catherine of Siena Church to initiate debit entries to my (our) checking
account or savings account indicated below at the financial institution named below. I (we)
acknowledge that the origination of ACH transactions to my (our) account must comply with the
provisions of U.S. law.
Bank Name:
_____________________________________________
Routing Number:
_____________________________________________
Account Number:
_____________________________________________
Checking Account:
(Please attach a voided check)
or
Savings Account:
(Please note if you choose to make your contributions on a monthly basis: Because there are 52
weeks in the year, please consider taking the yearly amount you wish to contribute and dividing it by
12 months. For example: $35 per week times 52 weeks equals $1,820 yearly; $1,820 yearly divided
by 12 months equals $151.67 monthly.)
Payment Frequency:
Weekly:
or
Monthly:
Contribution Amount: Weekly: __________
or
Payment Date:
Monthly:
Weekly: every Friday
_
Monthly: __________
5th or 25th (circle one)
Effective Date of first payment: ____________________________
This authorization is to remain in full force and effect until St. Catherine of Siena has written notification
from me (us) of its termination in such time as to afford St. Catherine of Siena and the depository a
reasonable opportunity to act on it.
Name (s):
________________________________
Address:
_____________________________________________________________________
Signature:
______________________________
Second Signature:
______________________________
Phone #:
Date:
________________
_________________
(if needed for joint account)