Authorization Agreement for Direct Donations (ACH Debits)
Name: ____________________________
I would like to take advantage of the security and convenience of electronic funds transfer for purposes of making
donations to Samford University.
As a duly authorized signer on the financial institution account identified below, I authorize you to perform electronic
funds transfer debits from the account listed below for contributions to Samford University. I acknowledge that the
origination of ACH transactions to my account must comply with the provisions of the U.S. law.
I further understand that if any such electronic debit(s) should be returned by my financial institution item fee of $25.00
(or the maximum amount allowed by state law) per item by electronic debit from the same account identified below.
For accounting purposes, all electronic debits will occur on or about the 15
of each month and will be reflected on the
monthly bank statement that corresponds with the financial institution account identified below.
This authorization is to remain in full force and effect until Samford University has received written notification of its
termination in such time and such manner as to afford Samford University a reasonable opportunity to terminate the
authorization. Any such notice should be sent to:
Samford University Controller’s Office 800 Lakeshore Drive Birmingham, AL 35229
___ Single donation of $ ________ or ___ Equal recurring monthly donation of $ _________
Gift designation(s): _________________________________________________________
I understand and authorize all of the above.
Signature: ___________________________
Financial Institution account “identifying information”:
Enter financial institution account information in the fields provided below or attach a blank VOID check.
Complete or
attach Blank
Voided Check
Financial institution:
Transit/ABA #
Account #
If you need help identifying your Transit/ABA# and Account #, see next page for diagram.