DONOR INFORMATION

Full Name

Address

City/State/ZIP

Phone

Email

BANK ACCOUNT INFORMATION

Bank Name

Account Holder Name

Routing Number

Account Number

Account Type

CheckingSavings

AUTHORIZATION DETAILS

Amount ($)

Frequency

MonthlyQuarterlyAnnuallyOne-Time

Start Date

Designation

Building FundGeneral FundPantryClinicOther

I authorize MAWV to initiate ACH withdrawals from the account listed above according to the schedule selected. This authorization shall remain in effect until revoked in writing.

I agree to the ACH authorization terms above.

Signature (Type Full Name)