ACH (Authorization for Electronic Contributions) Last Name(Required)First Name(s)(Required)Mailing Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Daytime Phone(Required)Name of Financial Institution(Required)Account Type(Required) checking savings Routing Number(Required)Account Number(Required)Main OffertoryParish SchoolTOTAL monthly gift(Required)(add the two amounts together)Recurring Frequency: check preference(s) belowFrequency(Required) once per month, on the 3rd of the month once per month, on the 18th of the month twice per month, on the 3rd and 18th of the month amount on the 3rd of the month(Required)amount on the 18th of the month(Required)Date to begin electronic withdrawals(Required) MM slash DD slash YYYY AUTHORIZATION AGREEMENT FOR DIRECT PAYMENT OF CONTRIBUTIONS (ACH DEBITS)(Required) I/we agree with the following Authorization statementI (we) hereby authorize Immaculate Conception Church to initiate debit entries to my (our) account listed above at the financial institution listed above and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law. This authorization will remain in full force and effect until Immaculate Conception Church has received written notification from me (us) of its amendment or termination in such time and in such manner as to afford Immaculate Conception Church a reasonable opportunity to act on it. In the event Immaculate Conception Church erroneously debits the above account, I (we) authorize Immaculate Conception Church to initiate adjustments and credit the account for an amount not to exceed the original transaction. I (we) understand it is my (our) sole responsibility and duty to verify that the above account has sufficient funds to honor the debit entry.CAPTCHAThank you for your continued support of Immaculate Conception Church!
