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Whitley County Democratic Central Committee

Authorization for Automatic Payment

I authorize the Whitley County Democratic Central Committee, and the Financial Institution below, to initiate deductions from my checking/savings accounts.  This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it.  I can stop payment of any deduction by notifying my financial institution three (3) days before my account is charged.  I can have the amount of an erroneous charge immediately credited to my account up to fifteen(15) days following issuance of my financial institution statement, or sixty (60) days after posting, whichever occurs first. ( I have attached my check marked VOID to this form below.)

Please Print

Amount of monthly debit: $_________, on the _________ day of each month.

Checking Account #_____________________________________________ OR

Savings Account#_______________________________________________

Financial Institution Routing Number ___________________________________       (between these symbols I: I: on the bottom left of your check)

Name of Financial Institution:__________________________________________________________

Financial Institutions Address:____________________________________________________________

Your Name:__________________________________________________________

Your Address:________________________________________________________

_______________________________________________________________

Please Staple "VOIDED" Check Here

PLEASE MAIL TO

WHITLEY COUNTY DEMOCRATIC PARTY

C/O TIM BLOOM

119 S. MAIN ST.

COLUMBIA CITY IN. 46725

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

KEEP FOR YOUR RECORDS

The Whitley County Democratic Central Committee Would Like To

THANK YOU!

Your contribution of $__________ Per Month, to be automatically deducted from you account on the _________ day of each month, is vital to the work of your Whitley County Democrat Party.