| COMPANY
NAME : HINDU TEMPLE OF ATLANTA,
INC. |
ID
NUMBER : 58-1602137 |
|
I
(we) hereby authorize THE
HINDU TEMPLE OF ATLANTA, INC.
Hereinafter called COMPANY, to
initiate monthly debit entries
to my (our) Checking account
indicated below and the bank
named below, Hereinafter called
DEPOSITORY to debit the same to
such account
|
| |
| DONOR’S
BANK NAME (DEPOSITORY)
_______________________________________ |
| |
| CITY_________________________
STATE ____________
BRANCH_________________ |
| |
| TRANSIT/ABA
NO. _________________________
ACCOUNT NO. ___________________ |
| |
| AUTHORIZED
DEBIT ENTRY AMOUNT $
_____________ |
|
This
authority is to remain in full
force and effect until COMPANY
and DEPOSITORY have received
written notification from me (or
either of us) of its termination
in such time and in such manner
as to afford COMPANY and
DEPOSITORY a reasonable
opportunity to act on it.
|
| |
| DONOR’S
NAME____________________________
DONOR’S SSN____-____-_______ |
| |
| |
| DATE________________________
SIGNED_________________________________ |
| |
| *Please
attach voided deposit slip or
check |
