Trinity Lutheran Church, Jefferson, Iowa

Congregation Contributions Form

[Print out this form and return to the church office]

Frequency of Funds Transfer:

Church Fund Designation:

Amount:

Weekly on Monday

General/Operating

$

Weekly on Friday

Missions

$

Semi-monthly [1st & 15th of each month]

TEAM Account

$

Monthly on the 1st

$

Monthly on the 15th

$

Start Date:  

Total

$

Name:

Address:

Phone:

Email:

New Enrollment/Authorization

Change in authorized Amount

Change in Account

Donations should be taken from:

Checking [attach voided check]

Bank Routing No._____________________________________

Savings [attach deposit slip]

Account No. _________________________________________

I authorize Trinity Lutheran Church to automatically withdraw contributions from my account.  I have attached

a voided check or a savings deposit slip. This authority will remain in effect until I give reasonable notification

to terminate the authorization. 

Authorized Signature:_____________________________________________Date:____________________

Privacy/Confidentiality Notice:  This authorization form will be seen by Trinity Lutheran Church employees.

Participant information will not be shared with any other organizations.