ACH Form for Automatic Contributions

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Basic 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.
Date REQUIRED Please fill out this field. Please enter a date.
Address 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 Maximum 20 characters Please fill out this field. Please enter a phone number.
Email REQUIRED Please fill out this field. Please enter an email address.
Parishioner Authorization
Effective Date REQUIRED Please fill out this field. Please enter a date.
Please select the appropriate option. REQUIRED New Authorization Change Contribution Amount Change Contribution Date Change Financial Institution Discontinue Contributions Please fill out this field.
Regular Church Fund
I/we wish our donations to be transferred to the Church at this time: REQUIRED Weekly (transferred beginning of week) Bi-Monthly (transferred on the 7th and 22nd of the month) Monthly (transferred on the 7th of the month) Monthly (transferred on the 22nd of the month) I do not wish to contribute to the Regular Church Fund at this time. Please fill out this field.
Amount (enter 0 if not contributing) REQUIRED Please fill out this field. Please enter valid data.
Building Fund
I/we wish our donations to be transferred to the Church at this time: REQUIRED Monthly (transferred on the 7th of the month) Monthly (transferred on the 22nd of the month) I do not wish to contribute to the Building Fund at this time. Please fill out this field.
Amount (enter 0 if not contributing) REQUIRED Please fill out this field. Please enter valid data.
Bank Account for Withdrawals
Please take my contribution directly from the account specified: Checking Savings
Routing Number Please enter valid data.
Account Number Please enter valid data.
I/we authorize the Church of Saint Anne to process debit entries to my account. After submitting the form, I will open the follow up email and send a picture of a voided check or savings deposit slip to St. Anne's per the instructions.
This authority will remain in effect until I give reasonable notification to terminate this authorization. REQUIRED Yes Please fill out this field.
Signature (type your full name) REQUIRED Please fill out this field. Please enter valid data.
Date REQUIRED Please fill out this field. Please enter a date.

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Saint Anne Catholic Church

Bismarck, ND

ACH Form for Automatic Contributions