Monthly Donation Form

Monthly Donation Form

For Donations from a Chequing Account
Donor Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Birth Date

MonthDayYear
Birth Date
Donation Information
Monthly Donation Amount*
Please enter the amount of your monthly donation (amount charged each month).
Payment Day*

1st of the month15th of the month
Banking Information

Note: The information below can be obtained directly from your bank, or can be found on your cheques as indicated in the image at the bottom of this section.
Financial Institution Name*
Please enter the name of the bank or financial institution your chequing account is with.
Transit Number*
Please enter your bank's transit (or branch) number.
Institution Number*
Please enter your bank's institution number.
Account Number*
Please enter your account number.
Pre-Authorized Debit Agreement
- I/we authorize U-Turn Parkinson’s to debit my/our account as indicated above for the purpose of monthly charitable donations.
- I/we agree to waive the right to receive pre-notification of each monthly debit, including the amount and the payment date. I/we understand that by signing this agreement, debits may be processed without prior notice, and only the terms specified in this agreement will apply unless otherwise amended verbally or in writing to U-Turn Parkinson’s at PO Box 23036, Winnipeg MB R3T 5S3.
- I/we may cancel this authorization at any time by providing 15 business days’ written notice to U-Turn Parkinson’s. To obtain a sample cancellation form, or for more information on my/our right to cancel a PAD Agreement, I/we may contact my/our financial institution or visit www.payments.ca.
- I/we have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on my/our recourse rights, I/we may contact my/our financial institution or visit www.payments.ca.
By signing below, I/we acknowledge that the above information is correct and understand all terms of the agreement:
Signature*

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Monthly Donation Form

Donor Information

Donation Information

Banking Information

Pre-Authorized Debit Agreement