Electronic Funds Transfer Form - Wipb
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1How to participate:
1.
Provide all the information requested below
2. Sign the authorization agreement at the bottom of this page
3. Enclose a voided check for the account to be debited
4. Return this information, including your voided check to
WIPB Public Television
Electronic Funds
Attn: Member Services
Ball State University
Transfer Form
Muncie, IN 47306
Questions? Call 800-252-9472 or 765-285-2982.
Financial Information
Personal Information
Name of Financial Institution
Name
Institution’s Street Address
Address
City
State
Zip
City
Institution’s Routing Number
State
Account Number
Zip
Account Type
o
Checking
o
Savings
Begin withdrawls in the month of
Year
Home Phone
End withdrawls in the month of
Year
Business Phone
Your monthly gift amount $ _______
Please read and sign this agreement
I/we hereby authorize Ball State University Foundation to initiate debits to the account indicated above in the
financial institution indicated. These debits will be made monthly and can be made by any means available to the
financial institution, including the electronic transfer of the funds involved.
This authority is to remain in full force until I/we request and increase or removal from the program by
contacting WIPB Public Television or the Ball State University Foundation in writing.
Your signature _____________________________
Spouse signature ______________________________
Date _____________________________
Date ______________________________
Thank you for your commitment to WIPB-TV!
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