I (we) hereby authorize CF Foundation, Inc. to initiate debit entries to my (our)
Checking Savings account (select one) indicated below at the depository financial institution stated below, hereinafter called DEPOSITORY, and to debit the same such account.

This authorization is to remain in full force and effect until CF Foundation, Inc. has received written notification from me (or either of us) of its termination in such a time and in such a manner as to afford CF Foundation, Inc., and DEPOSITORY a reasonable opportunity to act on it.

Initiator Name

Signature

Additional Name(optional)

Signature

Date

Note: all written debit authorizations MUST provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization. Cancellation can be done with a 30 day written notice. To initiate the debit authorization complete form, and mail a printed hard copy with a voided check to: