ACH Transfer Authorization

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Contact Information

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Account Information

Account Type*

Routing Number

Account Number

Transfer Information

The minimum monthly orphan sponsorship donation is $39 per child. You may also increase your monthly contribution to benefit our special initiatives and greatest needs.

Please Select The Amount You Wish to Contribute Per Child*

Other Amount*

How many total sponsored children?*

Total Transfer Amount*

Multiply your sponsored amount by the number of children. Amounts are transferred on the 5TH of each month.

Authorized Signature

By signing above: I (we) hereby authorize Covenant Mercies to withdraw the stated amounts by initiating debit entries to my (our) account at the financial institution indicated in this agreement. I understand that this authorization will remain in effect until I notify Covenant Mercies or my financial institution in writing in such time and manner as to afford Covenant Mercies and my bank reasonable time to act on it. Please allow up to five business days for your initial transfer request to be processed by the bank.

Full Name*

Signature*

Place cursor/finger in the box and click and hold for signature.

Comments

This field is for validation purposes and should be left unchanged.

ACH Transfer Authorization

Contact Information

Account Information

Transfer Information

Authorized Signature

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