Payment Authorization Form

Please fill out this form and click submit.

Congregation Name

*

Please select one option.

Prairie UU Church The Mountain Top UU

Type of Authorization:

*

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.

Monthly on the 1st Monthly on the 15th Semi-Monthly on the 1st and 15th Quarterly

Donation Amount:

*

Please select your method of payment below.

Banking Authorization

Please debit my (check one):

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.

American Express Discover MasterCard Visa

Card Number

Expiration Date

Billing Zip Code

Security Code (Back of Card)

AGREEMENT

I authorize Prairie Unitarian Universalist Church to process debit entries to my account. I understand that this authority will remain in effect until I provide reasonable notification to terminate the Authorization.

*

Please select all that apply.

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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