ACH Payment Form

University Congregational Church
      Authorization Agreement for Automated Payments
                  (ACH Debits)
University Congregational Church Tax ID: 48-0954936
I (we) hereby authorize University Congregational Church to initiate debit entries into my (our)
(   ) Checking  (  ) Savings Account (select one) indicated below at the depository
financial institution named below, hereinafter called DEPOSITORY, and to debit the
same to such account.  ( (we) acknowledge that the origination of ACH transactions to
my (our) account must comply with the provisions of U.S. law.
DEPOSITORY INFORMATION
Please Print:
Financial Institution ________________________________________________________
Your Name(s) __________________________________________________________________
Account Number ________________________________________________
Routing/ABA Number ____________________________________________
Frequency    (  ) Weekly (  ) Bi-weekly
Day of the week (circle one)       M     T     W     Th     F
    (  ) Monthly (  ) Semi-monthly
Date (circle one) 1st 15th
Amount $______________________________________
This authorization is to remain in full force and effect until University Congregational Church
has received written notification from me (or either of us) of its termination in such time
and such manner as to afford University Congregational Church and Depository a reasonable
opportunity to act on it.
DATE_________________________________
SIGNATURE________________________________________________________________
SIGNATURE________________________________________________________________
Please attach a VOIDED blank check.  Payments can begin within three weeks of turning
in this paper work.
UA-64457033-1