Authorization Agreement Form (Page 2 of 2) in pdf

Bank Information:

I/we authorize the University of Virginia to initiate debt entries to my/our bank account established at:

Financial Institution _______________________________________________________________________________________

Address/Branch Ofﬁce _____________________________________________________________________________________

City_______________________________________________ State _______________________ Zip ___________________

Transit/ABA Number _________________________________ Account Number _____________________________________

Type of Account

Checking

Savings

PLEASE ATTACH A VOIDED CHECK OR DEPOSIT SLIP.

Gift Designation:

I/we wish to make monthly gift payments of $ _______________________________ posting to my/our account for a period of:

Please check one:

6 months

12 months

24 months

36 months

until I request that you stop

Your gift deductions will begin 30 to 45 days after this initial authorization has been processed. Deductions will take place on or

about the 10th day of each month. Your monthly bank statement will itemize the drafts when they occur. Gift receipts will be

issued reﬂecting your gift designation choices.

This is a joint gift. Please also credit

________________________________________________________________________________________________________.

(Name of spouse, school, and class year)

I wish to make this gift anonymously.

Matching Gift:

Gifts to the University through employer matching programs are credited to the donor and count towards eligibility in gift clubs.

To ﬁnd out if your company or your spouse’s company matches gifts, contact your company’s human resources department.

Does your company match gifts?

Yes

Matching gift company name _______________________________________________________________________________.

I have enclosed my employer’s matching gift form.

Trusts and Estates:

I have included U.Va. or a related foundation in my bequest, estate plan, or charitable trust.

Authorization:

This authorization will remain in full force and effect until the University of Virginia has received written notiﬁcation from me

(or either of us) of its modiﬁcation or termination in such time and in such manner as to afford the University of Virginina

a reasonable opportunity to act on it.

Signature _____________________________________________________________________ Date ___________________

Signature, if joint account ________________________________________________________ Date ___________________

THANK YOU FOR YOUR GIFT.

Authorization Agreement Form Page 2