Name:Date of Birth:
Relationship to employee:Social Security Number:
Address:
Print Name:Date:
Signature:
I hereby authorize ARCHDIOCESE OF KANSAS CITY IN KANSAS, hereinafter called ARCHDIOCESE, to initiate, debit entries and adjustments for any debit entry in error to my account indicated below and the financial institution named below to debit and/or credit the same to such account. This authority is to remain in full force and effect until ARCHDIOCESE has received written notification from me of its termination in such time and in such manner as to afford ARCHDIOCESE and the financial institution a reasonable opportunity to act on it.
NamePhone Number
Financial Institution - NameFinancial Institution - Phone
Financial Institution- Steet Address
CityStateZip Code
Type of Account (check one)CheckingsSavings
Bank Routing numberBank Account number
Signature:Date:
