Credit/Debit Authorization Form

Thank you for committing to support Healing House on a recurring basis! Your ongoing support allows Healing House to more confidently plan for the future.

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First Name *
Last Name *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email
Phone
Name of Financial Institution *
Checking/Savings Account Number *
Financial Institution Routing Number (Look between these symbols l: :l on the bottom left of your check) *
Choose one designated fund *
Frequency *
Monthly/Semi-Monthly Payment Amount: *
Total Number of Payments
Agreement I (we) hereby authorize Healing House, Inc. to initiate entries to my checking/savings accounts at the financial institution listed above (The Financial Institution); and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until Healing House, Inc. is notified by me (us) in writing to cancel it in such time as to afford Healing House, Inc. and The Financial Institution a reasonable opportunity to act on it.
Signature * First Last
Today's Date *

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Credit/Debit Authorization Form

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