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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 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)

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:




_______________________________ _______________________________
Signature Date

_______________________________ _______________________________
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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