Loaves & Fishes Centers

• Home
•  » Give a Meal
•  » Ways To Give
•  » Monthly Giving - Big Fish Club
•  » Big Fish Authorization Form

Big Fish Authorization Form

Big Fish Club AUTOMATIC TRANSFER AUTHORIZATION

We invite you to join our convenient, transfer program which allows you to authorize your bank or credit card institution to transfer your monthly contribution on a predetermined date each month to Loaves & Fishes Centers, Inc. Each transaction is recorded as a deduction on your bank or credit card statement. Your ongoing support will help to ensure that no senior will go hungry or experience social isolation.

Instructions:

Simply complete and sign this agreement, and return it to Loaves & Fishes with a voided check.

Authorization Agreement for Loaves & Fishes’ Automatic Transfer of Funds

I authorize and request Loaves & Fishes to initiate electronic entries or use any other commercially accepted practice to charge my bank account (indicated below). I authorize and request the institution to honor the entries initiated by Loaves & Fishes Centers, Inc. This authorization will remain in effect until I request cancellation, which will require my notifying Loaves & Fishes Centers in writing.

Financial Institution Name: ___________________ Routing No. or Type of Credit Card _____________________________

Bank Account No. or Credit Card No. with Expiration Date_____________________________________________________

Your name: __________________________________Home phone _________________E-Mail:______________________

Your address:_______________________________________ City __________ State_____ Zip ______________________

Transfers to occur on the day of the month indicated (   ) 15^th of each month       (    ) 30th of each month

If a payment is due on a weekend or holiday, Loaves & Fishes will initiate a transfer on the next business day.

Amount to be transferred to Loaves & Fishes $__________      Start Date: Month _________, 200_______               

Name(s) as they appear on the bank account: ________________________________________________________________

3-digit credit card authorization code ________________________ (If using a credit card—located on the back of your card)

Your signature __________________________________________________Today’s date ___________________________

Anyone else whose signature is required to withdraw funds from this account must sign here:

____________________________________________________________________________________

PO Box 19477 – Portland, OR 97280-0477     503.736.6325

Loaves & Fishes is a 501(c)(3) organization, tax identification number 93-0584318.

Your gifts are 100% tax deductible as no goods or services were received for these donations.