THIS FORM IS TO BE USED ONLY IF YOU WISH NOT TO REGISTER BY

SUBMITTING THE ONLINE FORM.

Simply print this form, complete it, and return it to the church office.

AUTHORIZATION AGREEMENT FOR DIRECT WITHDRAWALS (ACH DEBITS)

FOR LEGACY DRIVE BAPTIST CHURCH     ID NUMBER 75-1658284

I (we) hereby authorize Legacy Church to initiate debit entries to my (our) ( ) checking ( ) savings

account (select one) indicated below at the bank named below to debit the same to such account.

ACCOUNT INFORMATION ( ATTACH A VOIDED CHECK)

BANK NAME_____________________________________BRANCH____________________

CITY________________________________STATE________ZIP CODE____________

ROUTING NUMBER______________________ACCOUNT NO.__________________

AMOUNT OF GIFT:   $___________________

TIMING OF GIFT:   

  ___ One Time

  ___ Once Per Month on the ___ 5 th or ___ 20 th

  ___ Twice Per Month   

This authorization is to remain in full force and effect until Legacy has received written notification from me

(or either of us) of its termination in such manner as to afford Legacy and the bank a reasonable opportunity

to act on it.

NAME(S)_________________________________ SS# _________________________

( PLEASE PRINT )

DATE _______________ SIGNED X_________________________________________

NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS SHOULD PROVIDE THAT THE RECEIVER

MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE

MANNER SPECIFIED IN THE AUTHORIZATION. PLEASE COMPLETE THE FORM ON

LINE OR SEND A NEW FORM.