200 Kennedy Memorial Drive
Waterville, ME 04901
Direct Payment Authorization Form
Name Last: ____________________________ First: ____________________________ MI: ___
City: _________________________________ State: __________ ZIP: ___________
I authorize the Inland Foundation to withdraw $___________________________ from my account listed below on the 1st of each month until I notify the Inland Foundation in writing for said payment to stop. The amount withheld each month is to be applied to:
(Inland Foundation, Inland Hospital, Lakewood, specific department, program, fund, or project)
Type of account: ____ Checking ____ Savings
Bank Routing No. : _____________________________________________________________
Your Account No. : _____________________________________________________________
Attach a voided check, or copy of a check, here if using a checking account. No deposit slips please:
Name (Please Print) Phone
Sample EFT Authorization Form (pdf)
This is a form that was uploaded as a PDF to a nonprofit’s website for donors to download.
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