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I (we) hereby authorize IICS to initiate debits from my credit card, checking or savings account, as specified below. I understand that both IICS and my financial institution reserve the right to terminate this payment plan or my participation therein. This authority is to remain in effect until revoked by me. Return this form with your voided check (if withdrawing from a bank account) to: IICS, P.O. Box 12147, Overland Park, KS 66282-2147. Date:_______________________________ Name(s):____________________________________________________________________________ Street Address:_______________________________________________________________________ City, State, Zip Code, Country:________________________________________________________ Home Phone:________________________________ Work Phone:______________________________ E-Mail Address:____________________________ To withdraw from a bank account, fill out this section: Financial Institution: ___________________________________________________________________ Bank Routing Number:________________________________________________________________ Bank Account Number:_____________________________________________________________ Type of Account (circle one): Checking Savings To charge your credit card, fill out this section: Card type (circle one): MasterCard Visa American Express Discover Name on card: ________________________________________________________________ Card number: ________________________________________________________________ Expiration date: ________________________________________________________________
Signature 1:________________________________ Signature 2:________________________________ I/We wish to support IICS with a monthly donation of: $_______________ Please debit my account every month on the (circle one): 5th 10th 20th 25th I/We wish to designate my/our gift to:
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