Authorization Agreement for Automatic Withdrawal of Funds

New Authorization

Change Financial Institution Information (Attach a new voided check or deposit slip)

Name/Address Change

Discontinue Automatic Withdrawal of Funds

Name (please print):
Street Address:
City:	State:	Zip:

Dollar amount for withdrawal will exactly match your scrip order total for any given week.

Dollar amount of withdrawal:	Exact amount of Scrip order
Frequency:	With each Scrip order placed
Deadline for order:	Mondays at 9:00AM

Please debit my scrip payment from (check one):

Checking Account (attach voided check or deposit slip)

Savings Account

Bank Routing Number:

(Located at bottom of check between the symbols ■0000000000■)

Account Number:

I authorize the St. Ursula Academy Scrip Program to process debit entries from my checking or savings account indicated above. I understand that this authorization will remain in effect until a cancellation request is submitted in writing. If I wish to cancel my authorization or make any changes to the above information, I will submit a new form to the St. Ursula Academy Scrip Program. I have attached a voided check below.

Signature:______________________________________________Date:___________________

Please attach your voided check or deposit slip here.