GEM EFT Form

EFT/ACH Monthly Giving Form

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Monthly Donation Amount *

If custom amount, please enter it here. *

Bank Account Number *

Routing Number *

Verification of Bank Account Number *

Electronic Funds Transfer: *

I authorize my bank to pay to FFLL each month the amount entered above according to the terms of the agreement below.

Verification of Routing Number *

Street Address, City, State, Zip *

Terms of Agreement:

MY AUTHORIZATION TO CHARGE MY CREDIT CARD OR TRANSFER MY MONTHLY ELECTRONIC FUNDS TRANSFER SHALL REMAIN IN EFFECT UNTIL I NOTIFY FFLL IN WRITING THAT I WISH TO END THIS AGREEMENT AND FFLL HAS HAD A REASONABLE TIME TO ACT UPON IT. A RECORD OF EACH PAYMENT WILL BE INCLUDED ON MY MONTHLY BANK OR CREDIT CARD STATEMENT AND WILL SERVE AS MY RECEIPT.

Electronic Signature *

First

Last

Date Signed *

Submit