Recurring Payment Authorization Form

Please fill out this form and click submit.

Type of Authorization

Please select all that apply.

*

Please select all that apply.

New Authorization Change Donation Amount Change Donation Date Change Banking Information Discontinue Electronic Donation

Effective Date of Authorization/Change

*

Date of 1st Donation:

*

Frequency of Donation

Please select one option.

*

Please select one option.

Monthly on the 1st Monthly on the 15th Semi Monthly Quarterly Other

If other selected, please specify

*

Donation Amount:

*

Banking Authorization

Please debit my (check one) optional

Please select one option.

Checking Account Savings Account

Legal Name on Account:

Routing Number:

Account Number:

Credit Card Authorization

Name on Credit Card

Type of Credit Card

Please select one option:

Please select one option.

American Express Discover MasterCard Visa

Card Number:

Expiration Date:

Billing Zip Code:

Security Code:

Agreement

I authorize First Unitarian Society of Denver to process debit entries to my account. I understand that this authority will remain in effect until I provide notification to terminate the Authorization.

Please select:

*

Please select one option.

Yes

Name

*

Email

*

This address will receive a confirmation email

Phone

*

Address

*

Description

Please fill out this form and click submit.

Please Fix the Following

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