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Spirit & Sustainability

Direct Withdrawal Authorization Form

I authorize my bank to charge my account and pay the scheduled amounts to Integrative Spirituality in accordance with the terms and conditions written below.

Please indicate the months and amounts of payments to be made by direct withdrawal:

*Amount per month $_____________ o­n the 20th of every month.

*Attach a voided check or a deposit slip printed with your account number.

*Mail the signed form with attached check or slip to mail it to The Integrative Spirituality, PMB 2167 1650 Casino Drive, Laughlin, NV 89029.

*Allow 4-6 weeks for this service to begin. The message o­n your monthly pledge reminder will indicate when your Direct Withdrawal has been set up. Please use a check or credit card to make any payments you have scheduled to be made within the next 6 weeks.

Name____________________________________________

Signature__________________________________Date____/____/____

Terms and Conditions:

My authorization to charge my bank account shall be the same as if I had personally signed a check payable to Integrative Spirituality. My authorization will remain in full force and effect until my bank or Integrative Spirituality receives my written notice of termination and they have had a reasonable opportunity to act o­n it, or until my bank or Integrative Spirituality has sent me ten (10) days written notice of termination of this agreement.

A record of each transfer will appear o­n my bank statement. This record will serve as my receipt.

I have the right to authorize my bank to reverse any transfer within fifteen (15) days after receipt of my bank statement or within forty-five (45) days after the transfer has been made.

I understand and agree that my bank shall have no responsibility for the correctness of my contribution and that any discrepancy in the amount shall be handled directly between Integrative Spirituality and me.