Monthly Pledge Authorization Form

Printed Name: ________________________________________

I hereby authorize Lonoke County Safe Haven to remind me of the pledge for the amount per month listed below.  I am attaching a check in the amount of my first pledge. Mail to LCSH, P.O. Box 414, Cabot AR  72023

I would like to pledge $______ and will send this amount to LCSH on the  _______ of each month. 

Signature:___________________________________________

Date: ______________________________________