ACH Authorization Form – Catholic Charities of North Louisiana

Electronic Funds Transfer Authorization (ACH)

Direct Payment via ACH is the transfer of funds from a consumer account for the purpose of making a payment.

To authorize Catholic Charities of North Louisiana to set up ACH payments:

Completing the electronic form below, or
Clicking here to complete our fillable authorization form, which can be emailed to [email protected] or mailed to CCNLA.

By completing this form, I (we) authorize Catholic Charities of North Louisiana to electronically debit my (our) account (and, if necessary, electronically credit my (our) account to correct erroneous debits) as follows, at the depository financial institution named below. I (we) agree that ACH transactions I (we) authorize comply with all applicable law.

Name *

First

Last

Phone Number *

Email Address *

Monthly Giving Amount *

Routing Number

If you would prefer a staff member from CCNLA will call you to set up draft information, please leave this blank.

Account Number

If you would prefer a staff member from CCNLA will call you to set up draft information, please leave this blank.

Financial Institution Name

Name(s) on Financial Institution Account

Authorization to Transfer Donation *

By selecting "I Agree," I authorize Catholic Charities of North Louisiana to perform a monthly electronic bank transfer in the amount listed above. I understand that CCNLA will contact me to set up the recurring payment if I did not complete the questions listed above. All recurring payments will be drafted on the 17th of each month unless otherwise directed.

Cancellation Agreement *

I (we) understand that this authorization will remain in full force and effect until I (we) notify Catholic Charities of North Louisiana by Phone: 318-865-0200 ext. 109, Email: [email protected] , or Mail: 902 Olive Street Shreveport, LA 71104 that I (we) wish to revoke this authorization. I (we) understand that Catholic Charities of North Louisiana requires at least 5 business days prior notice to cancel this authorization.

Signature *

I (we) agree that typing my (our) names above, I (we) consent to Catholic Charities of North Louisiana to authorize the electronic funds transfer (ACH) for the terms above.

Electronic Funds Transfer Authorization (ACH)

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