Pre-authorized Debit Agreement

I(we) authorize Kawartha Youth For Christ to debit my(our) account as indicated on the attached “void” cheque under the terms and conditions agreed to with KYFC until such time as written notice to the contrary is given. I(we) acknowledge that delivery of my (our) authorization to KYFC constitutes delivery by me(us) to the branch of the financial institution at which I(we) maintain an account and that such financial institution is not required to verify that the payment(s) are drawn in accordance with this agreement. I (we) will notify Kawartha Youth For Christ in writing of any changes in the account information, termination of this authorization, or change In the amount of the pre-authorized donation 10 business days prior to the next due date of the pre-authorized debit. I (we) warrant that all persons whose signature(s) are requested to sign on this account have signed this agreement.

Designate funds to:(Required)

Please put full name of staff
Donor Name(Required)
First Last
Is this a joint account(Required)
- Yes
- No
Name of joint account holder(Required)
First Last
Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email(Required)
Phone(Required)
Monthly donation amount(Required)

I (we) authorize KAWARTHA YOUTH FOR CHRIST to process a debit in paper, electronic or other form in the amount of
Withdrawn on:
- 1st
- 16th
of the month
Start with drawls on the following month(Required)
Please put the month
This donation is made on behalf of:(Required)
- an individual
- a business
upload a picture of blank/void cheque(Required)
Accepted file types: jpg, jpeg, png, gif.
account number
Bank number, transit number and account number
Consent(Required)
I(we) have signed below to acknowledge that I (we) have read and understood all of the provisions contained in the terms and conditions of the pre-authorized payment agreement and that I (we) have received a copy.
Signature(Required)
Date signed(Required)
MM slash DD slash YYYY
Signature of joint account holder(Required)
Date signed(Required)
MM slash DD slash YYYY
I have certain rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with this Pre-Authorized Debit Agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit www.cdnpay.ca
Total
$ 0.00 CAD

Designate funds to:(Required)

Please put full name of staff
Donor Name(Required)
First Last
Is this a joint account(Required)
- Yes
- No
Name of joint account holder(Required)
First Last
Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email(Required)
Phone(Required)
Monthly donation amount(Required)

I (we) authorize KAWARTHA YOUTH FOR CHRIST to process a debit in paper, electronic or other form in the amount of
Withdrawn on:
- 1st
- 16th
of the month
Start with drawls on the following month(Required)
Please put the month
This donation is made on behalf of:(Required)
- an individual
- a business
upload a picture of blank/void cheque(Required)
Accepted file types: jpg, jpeg, png, gif.
account number
Bank number, transit number and account number
Consent(Required)
I(we) have signed below to acknowledge that I (we) have read and understood all of the provisions contained in the terms and conditions of the pre-authorized payment agreement and that I (we) have received a copy.
Signature(Required)
Date signed(Required)
MM slash DD slash YYYY
Signature of joint account holder(Required)
Date signed(Required)
MM slash DD slash YYYY
I have certain rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with this Pre-Authorized Debit Agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit www.cdnpay.ca
Total
$ 0.00 CAD