Donation Electronic Payment Authorization Form
Smithlawn Maternity Home and Adoption Agency
P.O. Box 6451, Lubbock, TX 79493
806-745-2574

Donor SSN: ____________________________________________

E-Mail Address (if applicable): _____________________________

Organization Name:_______________________________________

Bank Name:_____________________________________________

Bank ABA Routing Number:________________________________

Bank Account Number:____________________________________

Checking_____ or Savings______             Effective Date   _________

          __5^th of each month draft in the amount of $__________

          __20^th of each month draft in the amount of $_________

I hereby authorize Smithlawn Home to debit by electronic transfer payments agreed to by me and, if necessary, credit entries and adjustments for any amounts debited electronically in error. Smithlawn Home shall debit the payments from the financial institution and account designated above. I recognize that if I fail to provide complete and accurate information on this authorization form, the processing of the form may be delayed or my payments may be erroneously transferred electronically.

This authorization is to remain in full force and effect until Smithlawn Home has received written notification from me of its termination.

I consent to and agree to comply with the National Automated Clearing House Association Rules and Regulations as they exist on the date of my signature on this form, or as subsequently adopted, amended, or repealed.

________________________________               _______________
Signature                                                                Date