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Direct Withdrawal
Direct Donation Authorization Form
I (we) hereby authorize WaterStone, Inc. to initiate entries to my checking/savings account
at the financial institution listed below, and, if necessary, initiate adjustments for any transaction credited/debited in error.
This authority will remain in effect until WaterStone is notified by me (us) in writing to cancel it in such time as to afford WaterStone and
the financial institution a reasonable opportunity to act on it.
Please attach a VOIDED Check to the form and return in the enclosed envelope or you may fax form to (719)447-4700
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Name of Financial Institution to withdraw from
_____________________________________________________________________________
Address of Financial Institution
Financial Institution Routing Number: ______________________________________________
Checking
Savings
Account Number: ______________________________________________________________
(check one)
Amount to be Withdrawn: $ _____________________ o Monthly o Quarterly
Minimum withdrawal is $25.00. Funds will be withdrawn the last Friday of the month or the last Friday of the quarter. Your statement will show a deduction from WaterStone, Inc.
My donation is recommended for Go Home Foundation #7528.
(Fund Name, i.e. John and Mary Smith Charitable Foundation)
___________________________________ ______________________________________
Signature (s)
____________________________________ _______________________________________
Name (Please Print)
_____________________________________________________________________________
Address (Please Print)
_________________________________________
Phone Number