| Name on Account (Please Print) | Account Holder's Daytime Phone # | |||||||||
| Address | Envelope # | |||||||||
| City, State, Zip | ||||||||||
| I authorize the following: |
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New Payment from Account Specified Below | ||||||||
| (one account only, please) | ||||||||||
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Changed Indicated Below | |||||||||
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Discontinue Electronic Funds Transfer from | |||||||||
| Account or Fund Specified Below. | ||||||||||
| Bank Account Information | ||||||||||
| (Provide Information below for one account only) | ||||||||||
| Bank Name | Bank Phone # | |||||||||
| Bank Addresss | ||||||||||
| Account |
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Checking (please attach voided check) | ||||||||
| Type |
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Savings (please attach deposit slip) | ||||||||
| Routing/ABA Number | Account Number | |||||||||
| Authorization Effective Date | / | / | ||||||||
| Fund Type | Payment Schedule | Amount | ||||||||
| Sunday Contributions |
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Weekly | Each Friday | $ | ||||||
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Monthly | 1st of each mo. | ||||||||
| Monthly Mortgage | Monthly | 1st of each mo. | $ | |||||||
| School Tuition | Monthly | 1st of each mo. | $ | |||||||
| Other | Monthly | 1st of each mo. | $ | |||||||
| I authoirize the above-named church or school to debit from the account specified on this form. This | ||||||||||
| authorization will remain in effect until I give reasonable change or cancellation notice to terminate | ||||||||||
| authorization. I understand there will be a $20 non-sufficient funds (NSF) fee charged to my account for | ||||||||||
| NSF debits. | ||||||||||
| Authorized account signature | Date | |||||||||
| For checking of savings account debits, please attach your voided check or savings deposit slip. | ||||||||||
| PLEASE RETURN THIS COMPLETED FORM TO: | ||||||||||
| ST. JOHN THE EVANGELIST | ||||||||||
| 502 S. PARK BLVD., STREAMWOOD, IL 60107 | ||||||||||
| Reminder: Attach VOIDED CHECK | ||||||||||
| And THANK YOU for your stewardship! | ||||||||||