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CUSH 2009 Sustaining Members
Drive
Print this
form for mailing to CUSH at the address above.
Name(s)____________________________________
Daytime Phone___________________
Address____________________________________ Email
__________________________
____________________________________
Congregation ____________________________
Option 1:
CUSH Sustaining Member Enrollment Form
m
Yes! I would like to become a CUSH Sustaining
Member by enrolling in the monthly giving program.
Electronic Funds Transfer –
Authorization Agreement for Direct Payments (ACH Debits)
I (we) hereby authorize CUSH to
initiate debit entries to my (our) Checking Account or Savings
Account for the amount listed below at the depository financial
institution names below or on the enclosed voided check. I
(we) acknowledge that the origination of ACH transactions to my
(our) account must comply with the provisions of U.S. law.
Please debit
$_________________from the selected account monthly. I
would like to begin in ______________ (month). Please debit my
account on the 16th.
Checking Account:
ATTACH A VOIDED CHECK (not a
deposit slip)
Or
Savings Account: ATTACH
A SAVINGS DEPOSIT SLIP or
fill in the information below.
Routing Number
_______________________________
Account Number ______________________________
This authorization is to remain
in full force and effect until CUSH receives written
notification from me (or either of us) of its termination in
such time and in such manner as to afford CUSH and the
depository financial institution a reasonable opportunity to act
on it.
Signature___________________________________________Date
_______________________
Signature___________________________________________ Date
_______________________
Option 2:
Annual Gift Form
m
Yes! I want to be a
Sustaining Member, but I prefer to make an Annual Donation
m
I have enclosed
a check for:
m$120
m $250
m $500 m
$1000
m Other __________
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