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| ELECTRONIC MONTHLY STEWARDSHIP |
I/ We authorize Shirdi Sai Mandir to initiate monthly debit entries from my/our account to Transfer funds in the amount of $____________ until further notice. I understand I am in full Control of my donation and this authority is to remain in full force and effect until Shirdi Sai Mandir has received written notification from me (or either of us) of its termination.
❏ Checking (Attach a voided check)
❏ Savings (Attach voided deposit ticket)
Account in the Name of: _____________________________________________________
Bank Name: _____________________________________________________________
Acct. #_________________________________ Routing # _________________________
Giver’s Name: ______________________________ Phone: ________________________
Address: ________________________________________________________________
City / State / Zip__________________________________________________________
Giver’s Signature: ___________________________________Date: _________________
E-mail: _________________________________________________________________
Would you like to be a Volunteer? ❏ Yes ❏ No
Please note that you can adjust, put on hold or cancel the monthly donation at any time. At
the year-end you will receive a statement from the Mandir stating donated amount. |
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INTERNAL DOCUMENT SHIRDI SAI MANDIR, DULLES, VIRGINIA |
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