St. Joseph Scrip Program

Authorization Agreement for Automatic Withdrawal of Funds

___  New Authorization                                    

____ Change Financial Institution Information (Attach a new voided check.)

___ Name/Address Change

___ Discontinue Automatic Withdrawal of Funds

Name (Please Print):_______________________________________________________

Address: ______________________________________________________________

City: ______________________________________   State: _______ Zip: __________

Dollar amount for withdrawal will exactly match your scrip order total for any given week.

Dollar amount of withdrawal: Exact amount of scrip order                               

Frequency: With each scrip order placed

Deadline for order: Monday, 8:00 am

ACH Deadline: Monday, 8:00 am

Please debit my scrip payment from (check one):

____Checking Account (attach voided check)

____Savings Account

Bank Routing Number: _________________________________           

(Located at bottom of check between the symbols ■0000000000■)

Account Number: ____________________________________________

I authorize the St. Joseph Scrip Program to process debit entries from my checking or savings account indicated above. I understand that this authorization will remain in effect until a cancellation request is submitted in writing.  If I wish to cancel my authorization or make any changes to the above information, I will submit a new form to the St. Joseph Scrip Program. I have attached a voided check below.

Signature: _______________________________________________Date:_______________________

  Please attach your voided check here.