Consumer Authorization For Direct Payments (Ach Debits) printable pdf download

CONSUMER AUTHORIZATION FOR DIRECT PAYMENTS (ACH DEBITS)

St. Joseph Church

4011 Alexandria Pike

Cold Spring, KY 41076

To authorize a direct payment from your checking or savings account to the parish for your Sunday offertory contribution fill

out the Consumer Authorization for Direct Payment You may return the completed form to the parish by mail or by way of the

Sunday collection basket.

Offertory envelope packets will continue to be mailed to your home as usual. You may still use the Sunday envelope by

checking the box on the envelope marked, “Direct Payment Made (ACH)” and drop it in the collection basket at Mass.

I (we) hereby authorize St. Joseph Church, herein after called “Church”, to initiate debit entries to my (our)

Checking / Savings (circle one) account indicated at the financial institution named below, and to debit the same to such

account.

This authorization is valid for withdrawal of $__________________ (amount) that will occur

monthly/semi monthly (circle one)

on the 1

/ 15

/ 30

(circle) day(s) of the month.

I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of the United

States law.

This authorization is to remain in effect until the Church has received written notice from me (or either of us) of its termination

in such time and in such manner to afford the Church and financial institution a reasonable opportunity to act on it.

Bank Routing #: _______________________________ Account #: _____________________________

City: _________________________________________ State: __________________________________

If joint account:

Name (Print): ______________________________

Signature: _________________________________

Date: _____________________________________

CHECK ONE:

ADD – Charge my account as shown above

I am currently participating in the Direct Payment Program

CHANGE – Change my financial institution and/or account number.

CANCEL – Stop my participation in the program.

PLEASE CHECK if you still wish to STOP receiving monthly envelopes

ATTACH YOUR VOIDED CHECK HERE

A copy of this Authorization for Direct Payment (ACH Debits) will be retained by the Church for a period of two years

following its date of termination either by the consumer or the Church. Copies of this authorization will be provided to any

related party within 60 days of receipt of a written request.

Initials of Church Contact reflect that a copy of this authorization has been provided to consumer.___________

Consumer Authorization For Direct Payments (Ach Debits)