Recurring Automatic Bank Transfers

Kindly print this form. Once you have completed it, please return it with a voided blank check or voided blank deposit slip (depending on whether the funds will be drawn from your checking or your savings account) to:

Friends of St. Paisius Monastery

P.O. Box 1075, Safford, Arizona 85548

Automatic Bank Transfer Authorization

I authorize St. Paisius Monastery to deduct funds from my bank account as indicated here:

Frequency (check one): _____Weekly; _____Bi-Weekly; _____Monthly*; _____Bi-Monthly*; _____Quarterly*; _____Annually*

Amount: $_______________

Begin transferring funds as of ________/_________ (month/year).

Enclosed is my VOIDED BLANK CHECK (if it is a checking account) or VOIDED SAVINGS DEPOSIT SLIP (if it is a savings account) to provide the information necessary for set up.

This authorization is to remain in effect until St. Paisius Monastery has received notification from me of its termination in such time and in such manner as to afford St. Paisius Monastery and the corresponding bank/s to act on it.

Name:________________________________________

Date:________________________

Signature:________________________________________________

*Optional: Please deduct funds around _______________________ (i.e., 1st of the month; 15th of the month; etc.)