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SRI MAALOLAN SEVA ASSOCIATION, INC.
(Tax ID: 75-2641081 {Non Profit 501(c) (3)} )AUTHORIZATION AGREEMENT FOR PRE-ARRANGED PAYMENT(ACH DEBITS)
I/We hereby authorize Sri Maalolan Seva Association, Inc. (SMSA) to initiate a debit entry in the amount of
$50 $75 $100 $150 $200 $250 $300 $350 $400 $500 Other ($ ) (Select one) on the 10th day of the first month of every calendar quarter (January, April, July, October) to my /our Checking ( ) Savings ( ) (select one) account indicated below at the bank named below
BANK NAME/BRANCH
BANK ADDRESS
Telephone
BANK TRANSIT/ABA NUMBERACCOUNT NUMBER
(Attach a voided check to this form)
This authorization is to remain in full force until SMSA has received written notification from me (or either of us) of its termination and in such manner as to afford SMSA and the above named bank reasonable opportunity to act upon it.
NAME (First Account holder) NAME (Second account holder)
SIGNATURE SIGNATURE
DATE DATE
ACCOUNT HOLDER ADDRESS
Telephone
Please be sure to fill out the Allocation Form and mail both the forms to
SVSS, 7821 W Alder Drive, Littleton, CO 80128-5522 |
