Contributor Information
Your Name (as it appears on your bank account): _____________________________________________________
Soc. Security #: _______________
Phone #: (_____) _____ - __________
Address: ___________________________________________________
City: __________________________ State: ______ Zip: _____________
Financial Institution Information
Financial Institution Name: __________________________________________________________________
Branch: ____________________________________ Account #: ___________________________________
Address: _______________________________________________________________________________
Routing #: __________________________________ Bank Telephone #: (______) ______ - ___________
Contribution Method
Please deduct $__________ from my (choose one) ______ checking ______ savings account.
(Choose one) _______ Monthly _______ Quarterly
Authorization
I hereby authorize ________________________________ to deduct my donation(s) from the account(s) listed above. I understand that I control my donations, and will notify you if at any time I decide that I want to discontinue the Automatic Payment service. This authority is to remain in full force and effect until written notice from me has been received by Hillsdale County United Way in such a manner as to afford reasonable time to act on it.
Date: ____________________ Signature: __________________________________________________________
Hillsdale County United Way, P.O. Box 203, 30 N. Howell St., Suite 21, Hillsdale, MI 49242