Date_______________________________________ Parish Envelope Number _______________

I authorize St. Stanislaus Parish and the financial institution named below to initiate entries to my checking/savings account. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment of any entry by notifying my parish three working days before my account is charged. Note – You will continue to receive your monthly envelope packet for special envelopes such as: Holy Days, Parish Improvement, Easter & Christmas Flowers, Retired Religious, DCCW and other special collections (unless you inform us to stop all envelopes.)

_____________________________________________________________________________________

(Name of Financial Institution)

___________________________________________________ _______________ _____________

(City) (State) (Zip)

Account #_____________________________________________________________________________

Financial Institution Routing #_____________________________________________________________

Amount $__________________________ ____Checking Account ____Savings Account

Circle one or both days for transaction: 5^th 20^th

(If you choose both dates, then one-half of the amount will be deducted on each date.)

_____________________________________________________________________________________

(Signature)

_____________________________________________________________________________________

(Name –PLEASE PRINT)

_____________________________________________________________________________________

(Address – PLEASE PRINT)

___________________________________________________ _______________ _____________

(City) (State) (Zip)

Please return this authorization form along with

a voided check to St. Stanislaus Parish. Thank you!