St. Anthony Catholic Church Frankfort, IL St. Anthony Catholic ...

Page Twelve — September 23, 2012St. Anthony Catholic ChurchSt. Anthony’s ChurchSt. 7659 Anthony West Catholic Sauk Street Church7659Frankfort,West SaukIL 60423TrailFrankfort, IL 60423Parishioner Authorization FormEffective date of authorization: ____________________________Type of Authorization:Last NameAddress New Authorization Change donation amount Change donation date Change Banking information Change Credit Card information Discontinue Electronic DonationFirst NameCity State ZipHome Phone:Email:Account InformationPlease choose either Banking information or Credit Card information. Provide information for one account only.Banking Information for Checking Account or Savings Account DebitsPlease debit my contribution from my (check one): Checking Account (attach a voided check) Savings Account (attach a savings deposit slip)Routing Number: _______________________________Valid Routing # must start with 0, 1, 2, or 3Account Number: _______________________________ Monthly on the 1 st Monthly on the 15 thDate of first contribution _____/_____/_____Amount Per Contribution $________________Credit Card Type Mastercard Visa Discover American ExpressCredit Card InformationCredit Card #:_______________________________Credit Card Exp. Date:________________________Date of first contribution _____/_____/_____Amount Per Contribution $__________________AGREEMENTI authorize St. Anthony’s and The Cunneen Company to process debit entries to my account. I understand that thisauthority will remain in effect until I provide reasonable notification to terminate the authorization.Authorized Signature:_______________________________________________________________ Date:________________Reminder:For Checking Account Debit: Please attach your voided checkFor Savings Account Debit: Please attach deposit slip