__$5  

Other $_______

*President’s Club Level

I/We authorize LCC Foundation to debit the amount indicated above each month to my/our account below and the Financial Institution named below, hereinafter called Financial Institution, to debit same to such account. I/We acknowledge the origination of Automated Clearing House transactions to my/our account must comply with the provisions of U.S. law.
 

Financial Institution

Branch

Address

City

Type of Account:

Routing/Transit Number

   Account Number

Please enclose a voided check as this will enable us to confirm your routing/transit number and your account number. Thank you.

This authorization shall remain in full force and effect until LCC Foundation has received written notification from me, or either of us, of its termination in such time and manner as to afford LCC Foundation and Financial Institution a reasonable opportunity to act on it.
 

I understand that a record of my gift will be included in my regular bank statements and will serve as my receipt.

Print Name(s)

Signature

Date