ACH Authorization Form

ACH Authorization Form

For DNI Funds, Projects, or Workers
If you would prefer to fill this out as a paper form click here to download a PDF.
I would like to make a change to an existing ACH.
I would like to make a one time donation via ACH
Personal Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Donation Information
Please specify the change that you would like to make.*
I would like to set up donations for:*

A specific DNI workerUndesignated worker supportThe DNI General FundA DNI fund or special project
Worker Name*
Contact us to view worker financial summaries.
Fund or special project*
Refer to the GIVE page for current funds and special projects
Amount*
To be withdrawn from your account monthly/one time
Account Information
Account Type

Checking AccountSavings Account
Month of first donation*
Day of month for transfer:*

5th of each month12th of each month19th of each month26th of each month
Routing Number*
Account Number*
Please upload an image of a voided check

Cancelof
Comments or special instructions
Make this gift anonymous.*

YesNo
Agreement
I authorize the Biblical Mennonite Alliance and Regions Bank to process debit entries to my account. I understand that this authority will remain in effect until I provide reasonable notice to terminate the authorization.
Full Name*
Date*
A tax-deductible receipt will be sent to you annually. (or within a month for one time donations) How would you like to receive this.*

MailEmail
Should be Empty:

ACH Authorization Form

Personal Information

Donation Information

Account Information

Agreement