ACH Debit Origination Authorization

S.E.N.T. Ministries Direct Monthly Donations Form Via the Northern California and Nevada District of the Assemblies of God Direct Withdrawal Monthly Donations ACH Debit Origination Authorization

I hereby authorize Assemblies of God, Northern California and Nevada District Council, Inc. (“Company”) whose Tax ID Number is 94-1399289 to initiate debit entries to the account indicated below (the “Account”) at the depository financial institution named below (“Depository”), and to debit the same to the Account. I acknowledge that the origination of ACH transactions to the Account must comply with the provisions of U.S. law.

ALL MONIES GIVEN/WITHDRAWN ARE COMPLETELY TAX DEDUCTABLE!!

Depository Name: ______Branch: ______City: ______State: ______Routing Number: ______Account Number: ______Account listed above is a Checking Savings account. (Please circle one) Deduct $______from my account on the 5th or 20th of the month. (Please circle one or both)

This authorization is to remain in full force and effect until Company has received written notification of its termination in such time and in such manner as to afford Company and Depository a reasonable opportunity to act on it.

First Name: ______Address: ______Last Name: ______Middle Initial: ______Phone # ______

Soc. Sec./Tax ID No.: ______District Account Number: 2602-351

______Signature Date

Please mail this form with all areas completely filled out to: DRC c/o Accounting 6051 South Watt Avenue Sacramento, Ca. 95829 If you would like to contact us directly, please do so at: 650-996-7407 [email protected] www.thesentministries.com