Monthly Donation ACH Authorization Form

ACH Monthly Donation Authorization

ACH=Automated Clearing House
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Amount per Month*
Day of Month*
Name of Financial Institution*
Name as it Appears on Account*
Routing Number*
Account Number*
Type of Account*
By signing this form, you authorize 350Vermont (350VT) to initiate monthly debit entries to the account at the bank named in this form. The authorization is to remain in effect until revoked by 350VT or until 350VT has received written notification from you of its termination. The notice of termination must be given reasonable time for 350VT to act prior to its effective date. To make changes to this agreement please contact 350VT at admin@350vt.org.

By signing this form, you also agree that you understand and acknowledge all ACH (Automated Clearing House) debit entries authorized by you will be conducted according to National Automated Clearing House Association (NACHA) rules. You further acknowledge that the origination of an ACH transaction must comply with U.S. law.
Signature*

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ACH Monthly Donation Authorization