Name *

First Name

Last Name

Preferred Phone *

(###)

###

####

Requested Action *

New Enrollment (Please indicate amount below)

Change Amount (Please indicate amount below)

Discontinue Auto Pay

Change Bank Information

Effective Date of Action

MM

DD

YYYY

Frequency of Withdrawals *

Twice Per Month - Withdraw 1/2 of the total amount on the 5th day of the month and 1/2 on the 20th day of the month.

Once per month – Withdraw the total monthly amount on the following day.

Once Per Month Enrollment

5th of Every Month

20th of Every Month

Authorization *

(By checking and signing below you authorize Zion City International Church Ministries, Inc. to set up auto pay with your financial institution in the amount specified above.)

I (we) authorize Zion City International Church Ministries, Inc. or its agent-representatives, to transfer the amount shown above from the account indicated on the enclosed check or savings deposit form on the dates indicated. This authorization will remain in effect until I (we) give reasonable notification otherwise. I (we) acknowledge that the origination to ACH transactions to my (our) account must comply with the provisions of U.S. law.

Date of Signature *

MM

DD

YYYY