AUTHORIZATION FOR DIRECT DEPOSIT



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An Interfaith Community Serving Those in Need



AUTHORIZATION FOR DIRECT DEPOSIT/PAYMENT

I hereby authorize People Helping People in Hernando County, Inc and Capital City Bank, Sunshine Grove Office to initiate entries for monthly ACH withdrawal from my checking/savings account in the amount indicated. I may revoke this authorization at any time by providing written notification to the attention of the Treasurer at the address below. Notification shall be made in such time as to afford the organization and the financial institution a reasonable opportunity to act on it. I can stop payment of any entry by notifying my financial institution at least 3 days before my account is charged.

______________________________________________________________________________

(Print Name)

______________________________________________________________________________

(Address)

___________________________________________________ __________ ______________

(City) (State) (Zip)

___________________________________________________________ _________________

(Signature) (Date)

€ Checking Account € Savings Account

Account Number: __________________________________________

Financial Institution Routing Number: _________________________________________

Amount of Withdrawal: $ _________________

My donation is:

€ Undesignated € Designated PHP € Designated Weekend Blessings

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Please retain a copy of this form for your records. Mail the original form to:

People Helping People in Hernando County

P.O. Box 6182

Spring Hill, FL 34611

Thank you for your support!

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