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I (we, if joint account) hereby authorize Girl Scouts of Manitou Council to initiate debit entries to my (our) checking/savings account at the financial institution indicated below.
The amount of the donation will be $
The frequency of the withdrawal of this amount will be:
One Time Monthly Quarterly Annually
Name of Financial Institution:
Type of Account: Checking Savings
This authorization will remain in force until Girl Scouts of Manitou Council receives written notification from me (or either of us) of its termination. I (we) may revoke this authorization at any time.
(The following serves as a signatures):
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