automatic bank withdrawal

AUTHORIZATION FOR MONTHLY DONATION BY AUTOMATIC BANK WITHDRAWAL

We/I request and authorize the Texas After Violence Project and my bank to set up a monthly
recurring donation in the amount of $______________ from my bank account, described below,
to the Texas After Violence Project.

This monthly withdrawal shall begin on or about the 5th of ________ (month), _______ (year) _______.

Signature of donor/account holder:_________________________________________________________

Please check only one:
______This monthly withdrawal shall end on _________ (month), ___________ (day) _________ (year).
OR
______ I/we will notify the Texas After Violence Project when to stop the automatic withdrawal.

Please use my/our contribution for the following purpose :

______Travel & interviews ______Equipment & Technology _______Training _______Wherever needed

and not for any purpose not alllowable under Section 501(c)(3) of the Internal Revenue Code.

Account Name: ___________________________________________________________________________

Name of Bank: ____________________________________________________________________________

Account Number: _________________________________________________________________________

Routing Number: _________________________________________________________________________

State of residence: ________________________________________________________________________

Printed name(s) of donor/account holder: _____________________________________________________

_________________________________________________________________________________________

Address of donor/account holder _____________________________________________________________

__________________________________________________________________________________________

______________ Yes, please list my name/our names on the Texas After Violence Project website.

______________ Please do not list my name/our names in public.

Mail the completed form to:

Texas After Violence Project
P.O. Box 41476
Austin, Texas 78704

Thank you for your support!