Name: _________________________  Address: _______________________

City: ___________________________  Postal Code: ____________________

Phone #: _______________________

Parish of: _______________________  Envelope #: _____________________

I/we authorize the e-offering administrator to debit my/our account

# ________________________  held at

Bank: _____________________

Location: __________________

Transit #: __________________

For the purpose of an offering to my Parish in the fixed amount of $__________, payable

(  ) every Sunday                or                (  ) the first of each month (check only one)

My/Our e-offering is to be allocated for:

(  ) General Parish use       - $__________

(  ) Other use (specify)        - $__________ 

_________________________________

and is to Begin : (date) ________________

I/We have read and understand the terms of this authorization and acknowledge receipt of a copy thereof.

(Signature)  ________________________  Date: _______________

(Signature) ________________________  Date: _______________

* All depositors must sign, only if more than one signature is required on the cheque.