AUTHORIZATION FORM

AUTHORIZATION FORM

The Simply Giving Program endorsed by Thrivent Financial Bank
School/Organization: Good Shepherd Lutheran School

This section for office use only. Please fill out form beginning at Student Information section.
Name of School:
Type of Authorization Form:

New AuthorizationChange Donation AmountChange Donation DateChange Banking InformationDiscontinue Electronic Donation
PERSONAL INFORMATION
Name

First NameLast Name
Street Address
City
State
Zip Code
Email Address
example@example.com
TUITION PAYMENT PLAN
Please select how you want to pay tuition

12 Month Plan (Aug-July)10 Month Plan (Aug-May)One Time Payment
FIRST DONATION DATE
MM/DD/YYYY
Effective date of authorization

MonthDayYear
Date
Frequency of Payment:

Monthly on 15thMonthly on 1st
Please debit my payment from my:

Checking Account (attach a voided check below)Savings Account (contact your financial institution for Routing #)
Routing Number:
Valid Routing # must start with 0, 1, 2, or 3
Account Number:
AGREEMENT
I authorize the above organization 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.
Authorized Signature

Clear
Date

MonthDayYear
Date
If using a checking account, please attach a voided check or bring one to the school office.

Cancelof
Should be Empty:

School/Organization: Good Shepherd Lutheran School