» Automatic Donation Authorization

Donor Name*

First Last

Donor Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

I authorize FaithBuilders to start transactions and recur monthly on this day of the month:*

Please enter a number from 1 to 28.

I authorize FaithBuilders to credit an automatic transaction for my monthly donation of this amount:*

Name on Account*

Type of Account*

Checking
Savings

Account Number*

Routing Number*

Name of Financial Institution*

This payment authorization is to remain in effect until I notify FaithBuilders of its cancellation by sending written notice in such time and in such manner to allow both the Organization (FaithBuilders) and the receiving financial institution a reasonable opportunity to act on it. I authorize FaithBuilders to initiate debit entries and, if necessary, initiate credit correction or adjustment entries to my (our) account at the Financial institution indicated above. Please attach a voided check or financial institution verification letter for account validation.

Donor Signature*

Email

This field is for validation purposes and should be left unchanged.

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