ACH FORM — World Services for the Blind

World Services for the Blind Contribution Authorization Agreement

I hearby authorize World Services for the Blind (WSB) to withdraw funds from my account by initiating debit entries to the financial institution named below. In the event that WSB withdraws erroneously from my account, I authorize WSB to credit my account for the amount erroneously withdrawn. This agreement will remain in effect until WSB receives a written notice of cancellation.

WSB will process your contribution on or around the 25th of each month unless you indicate another date in the form below. For questions, please contact us.

Contribution Details

Frequency

Account Type

Checking

Savings

Credit

Contribution Amount

Payment information for chosen method

Direct Deposit

Please enter your routing number and account number.

Credit Card

Please enter your credit/debit card number, expiration date, and security code.

Signature

Name

First Name

Last Name

Address

Include full address, city, state and zip code.

Email Address

Signature

By completing this section, I authorize World Services for the Blind to initiate debit entries based upon the above information.

Date

YYYY