Recurring Donation Authorization Form printable pdf download

Recurring Donation Authorization Form

Schedule your donation to be automatically deducted from your bank account, or charged to

your Visa, MasterCard or Discover card. Just complete, sign and return this form to get started!

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your checking/savings account or credit card. You will be

charged the amount indicated below each billing period. A receipt for each payment will be emailed to

you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior

notification will be provided unless the date or amount changes, in which case you will receive notice

from us at least 10 days prior to the payment being collected.

Please complete this form, attach a voided check and mail to WHS, PO Box 44, Versailles, KY 40383.

I ____________________________ authorize the Woodford Humane Society to charge my account indicated

(please print full name clearly)

below in the amount of $ _____________ on (check one)

the 15

day of each month, or

the 25

day of

each month or

once per quarter.

Billing Address __________________________________________ Phone ________________________________

City, State, Zip ________________________________________ Email ___________________________________

Checking/ Savings Account

Credit Card

Checking

Savings

Visa

MasterCard

Discover

Name on Acct ____________________________________

Bank Name ______________________________________

Cardholder Name___________________________________

Account Number__________________________________

Account Number___________________________________

Bank Routing # ___________________________________

Expiration Date____________________

Bank City/State __________________________________

CVV (3 digit number on back of card) ___________________

(note we cannot accept American Express transactions at this time)

SIGNATURE ______________________________________________________ DATE

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the Woodford Humane Society in writing of any changes in

my account information or termination of this authorization at least 15 days prior to the next billing date. The mailing address is Woodford Humane Society, PO Box

44, Versailles, KY 40383. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business

day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account

as soon as the above noted periodic transaction dates. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of

U.S. law. I certify that I am an authorized user of this bank/credit card account and will not dispute these scheduled transactions with my bank or credit card

company so long as the transactions correspond to the terms indicated in this authorization form.

Recurring Donation Authorization Form

Related Articles

Related forms

Related Categories