ACH Form Order Number Thank you for supporting Community Kitchen through the Automatic Transfer Program! Please complete this form in order to begin your automatic contribution. You may stop this contribution at any time simply by notifying us in writing. AUTOMATIC TRANSFER AUTHORIZATION -Authorization for Preauthorized Fixed Payments (ACH Debits) I hereby authorize COMMUNITY KITCHEN OF MONROE COUNTY, INC. to make scheduled withdrawals from the account identified below and authorize the Depository Financial Institution to charge such withdrawals to my listed account. Each withdrawal shall be equal to Amount and payable: Withdrawal Interval * Weekly Monthly on the 1st or 15th (Choose one below) of each month Semi-monthly on the 1st AND 15th of each month Quarterly on the 1st day of each quarter’s first month If weekly, what day of the week? Weekday If monthly, what day? Day 1st 15th The first such withdrawal is authorized for (date): withdraw date If the purpose for withdrawals is restricted in any manner, such restriction is stated below. Adjusting entries to correct errors are also authorized. It is agreed that these withdrawals and adjustments may be made electronically and under the Rules of the National Automated Clearing House Association. This authorization will remain in effect until written notice of termination is given to Community Kitchen. I acknowledge receipt of a filled copy of the authorization. Name of Depository Financial Institution: Financial Institution Account * Confirm Account * Accounts must match! Routing Number * Confirm Routing Number * Routing numbers must match! Type of Account * Checking Savings Name * Date * Email Address * Phone * Name on Receiving Account: COMMUNITY KITCHEN OF MONROE COUNTY, INC. Limitations on purpose for withdrawal: Charitable Contribution
