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Inland Foundation
200 Kennedy Memorial Drive
Waterville, ME 04901
(207) 861-3377

Direct Payment Authorization Form

Date: _______________________________

Name Last: ____________________________ First: ____________________________ MI: ___

SSN: _________________________________

Address: _____________________________________________________________

City: _________________________________ State: __________ ZIP: ___________

Phone: _________________________________

I authorize the Inland Foundation to withdraw $___________________________ from my account listed below on the 1^st 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)

Account information:

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:

Sincerely,

_______________________________ _______________________________
Signature Date

_______________________________ _______________________________
Name (Please Print) Phone