Automatic Bank Withdrawal Authorization

Thank you for commitment to CrossCounsel International Ministries, Inc. (CCIM). When completed and signed, this form authorizes CCIM to withdraw funds specified by you from your checking or savings account according to the choices made below.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Bank Account Information

Bank/Financial Institution Name

Account Type

Checking

Savings

Bank Routing Number

Bank Account Number

Donation Amount

I authorize withdrawals to be made on these occasions. Please check all that apply:

A special one-time amount

Every 15th of the month

Every 30th of the month

Session payments, special donations, outing fees or sponsorships (amounts vary)

If your designated giving day falls on a weekend or Federal holiday, the deduction occurs the previous banking day. For those who choose every 30th of the month, February’s deduction will appear on the last banking day of the month.

My submission of this form authorizes CCIM and my financial institution listed above to withdraw the amount(s) listed above from my account. This includes my authorization for CCIM to reverse any charges made in error. This authority will remain in effect until I give written notice to cancel it. I understand that in order to automate recording of my donation, CCIM may store my bank account information in their donor base software.

Please type your name here

Date

YYYY