Pre-authorized Monthly Donation -- Service Authorization Agreement

I (we) authorize Siloam Family Health Center and the financial institution listed below to electronically debit my (our)

q Checking account or   q Savings account specified below:  

___________________________________________________________________________________________________

 Donor’s Name/s      (PLEASE  PRINT)

___________________________________________________________________________________________________

Donor’s Mailing Address (PLEASE  PRINT)

___________________________________________________________________________________________________

(Area code) and phone number

___________________________________________________________________________________________________

Bank Name and Address of Branch

__________________________________________________________________________________

Bank Transit/ABA Number                                                                               Checking/Savings Account Number

Yes, I would like to provide a day of loving, compassionate, health care to those in need.

q     I want to pledge a monthly gift of $200.00 (equals $2,400 annually to cover the cost of operating the clinic for one day)

q     I want to pledge a monthly gift of $100.00

q     I want to pledge a monthly gift of $75.00

q     I want to pledge a monthly gift of $50.00

q     I want to pledge a monthly gift of $25.00

q     I want to give a special gift of $ __________ to be deducted monthly

The automatic draft shall begin during this month, ____________ and will recur on the 1^st of each month thereafter until I give 30 days written notification to stop the automatic draft to both Siloam Family Health Center and the bank listed above.  Please allow 45 days for the first draft to appear.

___________________________________              _________________________________

Authorized Signature                                                        Date

Please print this form and staple a check marked “void” and mail to:

Siloam Family Health Center

P.O. Box 41687

Nashville, TN 37204

Siloam Family Health Center is a 501(c)(3) nonprofit organization.  All donations are tax deductible to the extent

 allowable by law.  For further information, please phone 615/298-5406.

Thank you for helping to share the love of Christ by serving those in need through health care.