Consumer Authorization for ACH debit
Our Lady of the Mountain Roman Catholic Congregation, Inc.201 North Centre Street, Cumberland, MD 21502301-777-1750 ACH Offertory Authorization FormI (we) authorize Our Lady of the Mountains Roman Catholic Congregation, Inc. to electronically debit my (our) account (And, if necessary, electronically credit my (our) account to correct erroneous debits) as follows: (Weekly debits will occur each Friday)Name: ____________________________________Address: __________________________________ __________________________________Phone: ___________________________________ FORMCHECKBOX Checking Account (please attach a voided check) / FORMCHECKBOX Savings Account at the depository financial institution named below.I (we) agree that ACH transactions I (we) authorize comply with all applicable law.Depository (BANK) Name: ___________________________Routing Number: _________________________ Account Number: _____________________________Amount of WEEKLY debit: ___________________Date of first WEEKLY debit: __________________Other frequency of debit: _________________Other amount of debit: _________________ I (we) understand that this authorization will remain in full force and effect until I (we) notify Our Lady of the Mountains in writing, by phone, or in person that I (we) wish to revoke this authorization. I (we) understand that COMPANY requires at least 7 days prior notice in order to cancel this authorization.Name(s): ___________________________________//_______________________________________ (Please Print) (Please Print)Date: __________ Signature(s): ____________________________//____________________________FOR COMPANY USE ONLYNote: Signed authorization must be retained for a period of two years following the termination of revocation of the authorization.Date Received: _______________________________ Processed by: _______________________________ ................
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