Douglas Congregational United Church of Christ

Authorization Form

UCC320890

FOR OFFICE USE ONLY

DONOR #

DATE

Effective date of authorization: ___________________________

Type of Authorization Form:

q New authorization q Change donation amount q Change donation date

q Change banking/credit card information q Discontinue electronic donation

Last Name

First Name

Address

City

State

Zip

Date of first donation:

Frequency of donation: (please check only one)

Designated amount:

______/______/______ Date of last donation (optional): ______/______/______

q Weekly – Mondays q Semi-Monthly – 1^st and 15^th q Monthly on the 1^st q Monthly on the 15^th

q General/Operating

$ __________

Special Instructions:

CREDIT CARD

Please charge my donation to my (check one):

q Visa

q MasterCard

q American Express

q Discover Card

Credit Card Number:

Expiration Date:

Name on Card:

Billing Address (if different from above):

I authorize the above church and Vanco Services, LLC to charge my credit card for StillspeakingMoney^® in accordance with the information above. Signature (as it appears on the credit card): ____________________ Date: ________________

CHECKING / SAVINGS

Please debit my donation from my (check one): q Savings Account (contact your financial institution for Routing #) q Checking Account (attach a voided check)

Routing Number: ________________________________ Valid Routing # must start with 0, 1, 2, or 3 Account Number: ________________________________

I authorize the above church and Vanco Services, LLC to process debit entries to my account for StillspeakingMoney^®. I understand that this authority will remain in effect until I provide reasonable notification to terminate the authorization. Authorized Signature:___________________________________ Date:________________

Please return this form to the church office for processing.