AutomaticWithdrawal.pdf

This form gives authorization for funds to be given automatically.

Bethlehem Baptist Church
Automatic Withdrawal Authorization

___New Enrollment  ___Change in Contribution  ___Change in Account

Name: ____________________________________________

Address: __________________________________________

City State Zip: _____________________________________

Phone: ____________________________________________

Fund Designation  

Church/Mission $___________/ Month

Treasuring Christ Together (TCT) $___________/ Month

Helping Hand $___________/ Month

Total $___________/ Month

Date for first Contribution: _____________

Frequecy Cycle (check one):

___ Monthly

___ Twice a month (1st & 16th)

___ Biweekly

___ Weekly

Please attach a voided check or savings deposit ticket of the account that will be debited. The debit transactions will occur on the 15th of each month.

I authorize Bethlehem Baptist Church to process debit entries to my account. I have attached a voided check or savings slip. This authorization will remain in effect unit I give a reasonable notification to terminate this authorization.

Signature___________________________     

Date________________________________

Send this completed form to:

Paul Johnson
Financial Secretary
Bethlehem Baptist Church
720 13th Ave. S.
Minneapolis, MN 55415