Electronic Funds Transfer Enrollment Form
Authorization Agreement for Pre-authorized Payments

I hereby authorize the Society of St. Vincent de Paul of San Mateo County to initiate electronic debit entries to my account indicated below to fulfill my contribution to the annual fund. I am supplying my financial institution’s name and my account number below.

Depository Bank                                                                      City                                                      State/Zip

Account Number

I authorize $_______________________ to be deducted from my account on the _________________ date of every month.

This authorization is to remain in effect until the Society of St. Vincent de Paul of San Mateo County has received written notification from me of its termination/modification in such time and in such manner as to afford the Society of St. Vincent de Paul of San Mateo County a reasonable time to act on it.

Print Name: _________________________________________________________________________________________________

Signature: ______________________________________________________________________ Date: _______________________

***A VOIDED CHECK MUST BE ATTACHED TO THIS ENROLLMENT FORM***
Return form and voided check to:
Margaret Jung
Director of Development
Society of St. Vincent de Paul of San Mateo County
50 North B Street, San Mateo, CA 94401
Call 650-373-0622 with questions.