AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS

Organization Name *

Tax ID Number *

Organization Address *

Organization Address

City

State/Province

Zip/Postal

Phone Number *

I (we) hereby authorize United Way of the River Cities, Inc., hereinafter called UNITED WAY, to initiate credit entries to my (our) Checking Account or Savings Account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Checking Account

Savings Account

Depository Name *

Financial Institution Address *

Financial Institution Address

City

State/Province

Zip/Postal

Routing Number *

Account Number *

This authorization is to remain in full force and effect until UNITED WAY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Name *

Email *

Date *

Signature *

Clear

NOTE: ALL WRITTEN CREDIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

Website/URL

If you are human, leave this field blank.