Authorization Agreement for Automatic Withdrawal of Funds

Direct Payment Authorization Form Please return completed enrollment form to the UUFH: 109 Browns Rd., Huntington, NY 11743

Complete this section for ALL ENROLLMENTS (Please print in black ink)

Check the appropriate box: Last Name First Name M.I.  New enrollment/authorization * Mailing Address  Change in bank account * City State Zip  Change in authorized amount Home Telephone # Other Telephone #

CONTRIBUTIONS AND DONATIONS

To: Unitarian Universalist Fellowship of Huntington Street Address: 109 Browns Road City: Huntington State: NY Zip: 11743

Fund Designations: Amount Per Donation: Frequency of Donation: (Please check only one) ______Pledge, Current Year______$______ Weekly on Monday ______Wish List __ $______ Weekly on Friday ______Memorial Fund ______$______ Semi-monthly (transferred on 1st and 15th of each month) ______Minister’s Discretionary Fund $______ Monthly on the 1st ______Other: ______$______ Monthly on the 15th TOTAL DONATION AMOUNT $______(minimum $5) Date of First Donation ______Note: The total amount transferred will be based on the frequency selected.

Complete this section if you want donations to come from your CHECKING OR SAVINGS ACCOUNT

Donations should be taken from: REQUIRED:  Checking (attach a voided check) I authorize Unitarian Universalist Congregation of Huntington and Vanco Services to automatically withdraw donations from my account. I have attached  Savings (attach a savings deposit slip) a voided check or savings deposit slip. This authority will remain in effect until I give reasonable notification to terminate the authorization. Routing Number ______Valid Routing # must start with 0, 1, 2, or 3 Account Holder Signature ______Account Number ______Date ______

* ATTACH A VOIDED CHECK OR SAVINGS DEPOSIT SLIP FOR A NEW ENROLLMENT OR CHANGE IN BANK ACCOUNT ONLY

For Office Use:

Congregation Code : Envelope Number ______Verifier Initials ______ENROLLMENT INSTRUCTIONS: 1. Using black ink, complete the personal information section including name, address and telephone numbers. 2. Indicate whether this is a new enrollment/authorization, a change in amount, or a change in bank account. 3. Indicate the account type, routing number and account number. Attach a voided check or savings deposit slip to the enrollment form for a new enrollment or change in bank account. 4. Sign and date the Account Holder Signature section. 5. Complete the appropriate section with the institution name and address that will benefit from your giving.  Designate which fund(s) your donation should go to and the amount.  Select the frequency of your offering.  Select the date of the monthly donation transfer and the amount of each monthly donation.  Determine the date of your first and last donation. 6. Return the completed enrollment form. THANK YOU!