Impact Bethel
468 N Dayton Lakeview Rd
New Carlisle, OH 45344
Federal Tax ID 26-2365904
Phone: 937-765-1903


Impact Bethel Debit Authorization

Donor Name: ____________________________________________________________

Donor Address: __________________________________________________________

_____________________________________________

Phone Number: __________________________________________________________

Please DEBIT my account as follows:

Name of Financial Institution: _______________________________________________

Financial Institution Routing Number: ________________________________________

Donor Account Number: ___________________________________________________

Start Date: ______________________________________________________________

Dollar Amount of Withdraw/ Debit: __________________________________________

Type of Account (savings/ checking) : ________________________________________

Frequency (one-time, weekly, bi-weekly, monthly): _______________________________


Note: Enclose a voided check with this form.


I authorize Impact Bethel to debit the account listed above. I understand that if I decide
to discontinue the ACH debit, I will notify Impact Bethel in writing at the following address:

Impact Bethel
468 N Dayton Lakeview Rd
New Carlisle, OH 45344

Donor / Account Owner Signature: ___________________________Date:___________

This is an acknowledgment that the origination of ACH transactions to the donors
account must comply with the provisions of the U.S. law.