Monthly Auto Pay Authorization Form

Printed Name: ________________________________________

I hereby authorize Lonoke County Safe Haven to charge my checking account for the amount per month listed below.  I am attaching a voided check with my bank’s tracking number and account number.  Mail to LCSH, P O Box 414, Cabot AR  72023

Bank Name: ________________________________________

Branch: ________________________________________

City: _____________________ State ___ Zip _____

This authority is to remain in full force and effect until Lonoke County Safe Haven and the Bank have received written notification from me of its termination within 30 days of termination as to afford reasonable opportunity to act on it.

Amount of $ ________ is to be debited on the 1^st ______ or 15^th ____ of each month. 

Signature:___________________________________________

Date: ______________________________________