Authorization Agreement for Direct Debit Gifts

Please print this form, then mail a completed copy to your banking institution, as well as a copy to CSB to activate a direct debit (or electronic funds transfer) gift.

I (We) hereby authorize the College of Saint Benedict to initiate debit entries to my (our) checking/savings account indicated below at the depository named below.  I (We) authorize scheduled debits to the account below for the following amount:

Monthly on the first day of the month $_____________

Quarterly on the first day of the quarter $_____________

Annually on the first day of the year $_____________

Date of first authorized debit entry: ___/01/___

Date of last authorized debit entry: ___/01/___

The gift is to be applied as follows:    Annual Fund $________          

Other $________ (Please specify:________________)

Depository Name and Branch__________________________ For verification

City _____________________ State ____Zip_____________ purposes, please

Depository 9-Digit Routing Number _____________________ attach a void check

Name(s) of Account Holder(s)__________________________ to this form.

Account Number____________________________________

Account Type _____Checking ______Savings

This agreement is to remain in effect until the College of Saint Benedict and my (our) depository have received written notification from me (or either of us) of its termination in such time as to afford the College and my Depository a reasonable opportunity to act on it.

Authorization Signature(s) ______________________ Date_______

___________________________________________ Date_______

Thank you!