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					                                       Authorization Form for Direct Payment
I/we hereby authorize The Spine Foundation to initiate debit (withdrawal) entries and, if necessary, debit correction and
adjustment entries to my (our) account at the financial institution designated below:

Name of Financial Institution:

Routing and Transit Number:      ________

Branch Address:                  _______

Routing and Transit Number:      _______

Account Number:                  _______

Account Type (check one)                  Checking       Savings

Payments will be debited on the 1st day of the month. I/we understand that should the regularly scheduled debit date fall on a
weekend or Federal holiday, the debit shall occur on the following banking date.

I authorize equal monthly debit payments totaling $____ (total pledge divided by total number of months) beginning on the
first debit date after this authorization form is received by JLT and ceasing on ___ 1st, 20
                                                                                        Month             Year

This authority is to remain in full force and effect until The Spine Foundation has received written notification from the
recipient of its termination in such time and manner as to afford The Spine Foundation a reasonable time to act upon it.

Name

Address

Phone

Signature                                                        Date

               **Please attach a voided check or financial institution account verification letter to this form. **

__________________________________ Office Use Only

Monthly debit payment __________________

Start date __________________________________ End date ________________________________

				
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posted:1/1/2012
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