Monthly Automatic Bank Draft Request Form — Potter's Inn

Monthly Automatic Bank Draft Request Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(###)

###

####

Please select how you would like to designate your gift

Name of Bank or Credit Union

Account Number

Routing Number

Please withdraw this amount from my bank account automatically each month until further notice.

Month to begin withdrawals

Today's Date

YYYY

We will set up your monthly withdrawal as requested and let you know by email when it is complete. Additional comments or questions? Leave our Bookeeper a note here:

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