ACH/Direct Debit Increase Offering Form

- Parish Info

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- General Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Address (Street, Route, P.O. Box) REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  Email Please enter an email address.
  
  Envelope Number Please enter valid data.
  
  Do you want to receive envelopes? REQUIRED Yes No Please fill out this field.
- Current Donation
  
  Current Amount Please enter an integer (number).
  
  Current Frequency Weekly Reoccurring Monthly Reoccuring Envelope Schedule (includes special masses, holy days of obligation, lent and advent, etc)
- Increased Offering
  
  NEW Amount REQUIRED Please fill out this field. Please enter an integer (number).
  
  NEW Frequency REQUIRED Weekly Reoccurring Monthly Reoccuring Envelope Schedule (includes special masses, holy days of obligation, lent and advent, etc) Please fill out this field.
- Comments
- By clicking, "I Agree" I hereby authorize St. Agnes Parish to increase the current debit of funds from the account at the FINANCIAL INSTITUTION designated on my original authorization form, and I further authorize FINANCIAL INSTITUTION to debit the same to such account without responsibility for correctness of such amount. This authorization will remain in effect until I initiate the required stop action in such time and in such manner as to allow the above a reasonable opportunity to act upon it. I agree to notify St. Agnes Parish if I wish to change the designated FINANCIAL INSTITUTION or account from which funds are to be debited 30 days prior to the effective date of such change. I understand that failure to do so may delay the receipt of funds by St. Agnes
  I Agree Please select this field.
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