Authorization Agreement for Electronic Contributions

Catholic Area Faith Community of Jesus Our Living Water
Church of St. Mary.......Church of Our Lady of the Lakes
713 12th Street SW......6680 153rd Ave NE
Willmar, MN 56201.......Spicer, MN 56288
320-235-0118..............320-796-5664

Parish where my family is registered and to which contributions should be directed. *

Parish where my family is registered and to which contributions should be directed. Church of St. Mary, Willmar Our Lady of the Lakes, Spicer
I (we) hereby authorize The Church of St. Mary of Willmar, MN and the financial institution named below to initiate direct contributions from the account listed below. This authority will remain in effect until I (we) terminate it in writing. Such written notice will be given at least 10 business days prior to the effective date *

I (we) hereby authorize The Church of St. Mary of Willmar, MN and the financial institution named below to initiate direct contributions from the account listed below. This authority will remain in effect until I (we) terminate it in writing. Such written notice will be given at least 10 business days prior to the effective date Agree
I (we) hereby authorize The Church of Our Lady of the Lakes of Spicer, MN and the financial institution named below to initiate direct contributions from the account listed below. This authority will remain in effect until I (we) terminate it in writing. Such written notice will be given at least 10 business days prior to the effective date *

I (we) hereby authorize The Church of Our Lady of the Lakes of Spicer, MN and the financial institution named below to initiate direct contributions from the account listed below. This authority will remain in effect until I (we) terminate it in writing. Such written notice will be given at least 10 business days prior to the effective date Agree
Church Envelope Number (if known)
Account Holder Name (as shown on account) *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone * - ### - ### ####
Email *
Name of Financial Institution *
Routing Number (printed on lower left of checks) *
Account Number *
MONTHLY Amount of Contribution * $ Dollars . Cents
Date You Wish Amount to be Withdrawn from Your Account *

Date You Wish Amount to be Withdrawn from Your Account 1st of Month (OLOL) / 5th of Month (StMary) 15th of Month (OLOL) / 20th of Month (StMary)
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