I (we) hereby authorize THE HINDU TEMPLE OF ATLANTA, INC. 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.
DONORS 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 SS# ______________________
DATE __________________ SIGNED ____________________________________