134 Main Street South, Southbury, CT 06488 (203) 267-5441 http://www.calvarysouthbury.com [email protected] NOTE: YOU DO NOT HAVE TO FILL OUT YOUR BANKING INFORMATION IF IT IS PRINTED ON THE CHECK 1. I/we __________________________________________ hereby authorize Calvary Chapel Southbury to initiate debit entries to my/our checking account or savings account (select one) and the depository indicated below (hereinafter called DEPOSITORY) to debit the same to each account. 2. Your Name ____________________________ Your Address __________________________________________________________ 3. Bank Name ____________________________ Bank Address __________________________________________________________________ 4. Please attach a canceled check or fill out the lines below: TRANSIT/ABA # _______________ ACCOUNT # ________________________ 5. I would like this withdrawal to take place once per month on the first of the month. I would like this withdrawal to take place twice per month - on the first and the fifteenth of the month. The amount I/we wish to give is $______________ per transaction. This authority is to remain in effect until Calvary Chapel Southbury has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Calvary Chapel Southbury a reasonable opportunity to act upon it. NAME(S) Additional Information NAME (PLEASE PRINT) ________________________SIGNATURE ________________________ DATE____ NAME (PLEASE PRINT) ________________________SIGNATURE ________________________ DATE____ Please attach a voided check if a checking account is selected.