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Page Twelve — January 27, 2013St. Anthony Catholic ChurchSt. Anthony Catholic Church — Electronic Giving Authorization7661 West Sauk TrailFrankfort, 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 Vanco Cunneen Services Company to process to process debit entries debit entries to my account. to my account. I understand I understand that this that thisauthority will remain in in effect until I I provide reasonable notification to to terminate the the authorization.Authorized Signature:_______________________________________________________________ Date:________________Reminder:For Checking Account Debit: Please attach your voided checkFor Savings Account Debit: Please attach deposit slip