DonationACH

Donation ACH Form
Personal Information

The information given in this section is considered as the information of the primary account owner information.
Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com. Email will be used for the purpose of communication and email donation receipt.
Phone Number
Format: (000) 000-0000.
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Account Information
Bank Name
Name of the Bank
Account Type
Account Number*
Bank account number
Routing Number*
Bank routing number
Donation Amount
Amount*
Recurring donation amount in $
Frequency*
Date*

MonthDayYear
Select the date when you would like to start automatic deductions.
Agreement
By signing this form, I acknowledge that the information I've given in this form is accurate and I agree all the terms and conditions.

By signing this form I authorize Masjid Al-Haqq, under the Proclaim Truth Charitable Trust, to debit amount entered above from my bank account on the date entered in this form. This authorization will remain in effect until I provide written notice to cancel.
Date

MonthDayYear
Date
Donor Signature

Clear
Should be Empty:

Donation ACH Form