DePaul Community Resources_ Inc

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					                         DePaul Community Resources, Inc.
                                 5650 Hollins Road
                                Roanoke, VA 24019
                                   540-265-8923


                         Credit / Debit Authorization Form

I (we) hereby authorize DePaul Community Resources, Inc. to initiate a charge or
credit entry to my (our) checking/savings account at the Financial Institution listed
below, and initiate adjustment (if necessary) for any transactions credited/debited
in error. This authority will remain in effect until DePaul Community Resources,
Inc. is notified by me (us) in writing to cancel it in such time as to afford DePaul
Community Resources, Inc. and the Financial Institution reasonable opportunity
to act on it.

Name of Financial Institution:________________________________________

Location (city, state):_______________________________________________

Financial Institution’s Routing / Transit Number:__________________________

Checking Account Number:__________________________________________

AND / OR

Savings Account Number:___________________________________________

If split, state dollar amount for:

Checking                                  Savings Account:__________        ______

Today’s date:______________________

Foster Parent / Care Provider Name:___________________________________
                                              (PLEASE PRINT)

Foster Parent / Care Provider Signature:________                         _________

                            Please attach a voided check

				
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posted:12/4/2011
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