AGREEMENT FOR PREAUTHORIZED PAYMENTS TO THE UNITED WAY OF ETOWAH COUNTY

I hereby authorize United Way of Etowah County to deduct from my checking account $__________
(circle one) monthly/quarterly/semi-annually/annually beginning on ______ day of _________, 200___, and continuing until this pledge is paid.

Financial Institution: _________________________________________________________________

Please attach deposit slip of account to be debited.

PLEASE CHECK ONE OF THE BOXES BELOW:

• This authority is to remain in full force and effect until the United Way of Etowah County and the financial institution named above have received written notification from me of its termination in
such time and in such manner as to afford both parties a reasonable opportunity to act on it.
• For calendar year_________________

Account name____________________________ Date ________________________

Home Address:_____________________________________________________________

_________________________________________________________________

_________________________________________________________________

State:__________________• ZIP: _______ •Telephone:___________________

Signature ___________________________________________________