EmailMeForm
Direct Debit Form
I (we) authorize Stephen Memorial Animal Shelter (“COMPANY”) to electronically debit my (our) account and, if necessary, electronically credit my (our) account to correct any erroneous debits as follows: .
Name
First
Last
Address
Street Address
City
State / Province / Region
Postal / Zip Code
Phone
###
-
###
-
####
Email
Financial Institution Name
Account Type
Checking
Savings
Routing #
Account #
One Time Donation or Reoccurring
One Time
Reoccurring
Date of Payment or Start Date for reoccurring payments
MM
/
DD
/
YYYY
Frequency of payment (Reoccurring Payments)
Weekly
Bi-Weekly
Monthly
I (we) agree that ACH transactions I (we) authorize comply with all applicable laws, including the laws of the United States, as well as the provisions of the Nacha Operating Rules. I (we) understand this authorization will remain in full force and effect until I (we) notify COMPANY in writing to Email address smasadoptions@mahaska.org or mailed to PO Box 45, Oskaloosa, IA 52577 that I (we) wish to revoke this authorization. I (we) understand that COMPANY requires at least 10 days notice to cancel this authorization. For a Single Entry scheduled in advance, your revocation must afford COMPANY a reasonable opportunity to act on the revocation prior to initiating the payment.
Signature
Clear
