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Automatic Bank Withdrawal/Transfer-Authorization Agreement I hereby authorize BANK OF AMERICA, on behalf of Shiva Vishnu Temple, to initiate monthly withdrawals from my [ ] Checking [ ] Savings account (select one) indicated below,

and the financial institution named below to withdraw from such account. Deposited To: BANK OF AMERICA - ABA#: 122000661 ­- Acc. #:1102940428. La Jolla ­ 92122 Donor Information: Donor Name(s):____________________________________________________ Address:__________________________________ State:___ ZIP:____________ Phone:__________________________Email:_____________________________ Donation For: Pillar [ ] General/Pledge [ ] Temple Construction [ ] Membership [ ] Your Financial Institution Information: Please include a voided check. For savings account only complete the next four lines. Institution Name:____________________________________________________ Address:__________________________________________________________ Routing/ABA #: _____________________________________________________ Account No.:_______________________________________________________ Amount Per Transfer: $________ (must be $25 or more per transfer) Total Number of Transfers (months): [ ] 12, [ ] 24, [ ] 36, [ ] 48, [ ] 60, [ ] other ___ Start Date: ___________(mm/dd/yy) Day of month for Transfer:______________ (mm/dd/yy) _____________________________________________ DATE:__________ (Signature of Account Holder) _____________________________________________ DATE:___________ (Signature of Joint Account Holder) Please mail this completed form to: Shiva Vishnu Temple, 7930 Arjons Drive, Suite B San Diego 92126. Please include: voided Check below

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Microsoft Word - Automatic_Bank_withdrawl.doc

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