Authorization Agreement for Pre-Authorized Payments

(Direct Debits for Collection of Payments)

GREEN COUNTY HUMANE SOCIETY INC.

I (We-if joint) hereby authorize Green County Humane Society Inc. to initiate debit entries for $____________  Monthly or  Yearly and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my (our) checking account indicated below at the DEPOSITORY name below, to debit the same to such account.

Depository (Financial Institution) Branch No.

City, State, Zip

Routing and Transit # / ABA No. Account Number

****Please attach a copy of or a voided check****

This authority is to remain in full-force and in effect until either of us have received written notification of its termination in such time and in such manner as to afford Green County Humane Society Inc. a reasonable opportunity to act on it.

Name Identification Number (Office Use Only)

(X)

Date Signature of authorized signer on account

Available dates for withdrawal

q 10^th day of the month (X)_______________________________________

q 20^th day of the month Signature of authorized signer on account

q 30^th day of the month (if two signatures needed)

(Accounts considered joint unless the word and appears in the title or two signatures required)

q Membership Dues

q Sponsorship – CAT $180 per year/$15 per month

q Sponsorship – DOG $300 per year/$25 per month

q Donation