DONOR ACH FORM

Page 1

After filling out your personal and bank information on this form, you will be required to submit an E-signature. The E-signature will generate an email confirming your enrollment. You must click on the link in the email for the ACH to be effective. Please allow 2-3 business days for our accounting department to process your request.

Today's Date

Is this form being submitted on behalf of an organization?

YESNO

Page 2

Organization Name

First Name

MI

Last Name

Your title with this organization

Business Phone Number

Your Business Email Address

Phone Number

Personal Email Address

Your Home Address Line 1

Address Line 2

City

State

Postal Code

Page 3

FINANCIAL INFORMATION

Name of Financial Institution

Checking AccountSavings Account

Account Type

Account Number

Routing Number (Note: Confirm you have entered the "ABA" routing number. A bank may use more than one type.

TRANSACTION DETAILS

Amount (Enter U.S. Dollar Amount)

One-Time DonationMonthly Donation

Donation Frequency

5th Day of the Month15th Day of the Month25th Day of the Month

Preferred Transaction Date

**NOTE: If you have chosen a recurring donation your first transaction will take place on the first available day per your selected, preferred transaction date.