Pre-Authorized Debit Agreement

Your Information

Your Name

First Name

Last Name

Your Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Payment Information

Your donation will be charged monthly on the 16th of the month.

Partnership Amount

Other Amount

Banking Information

Transit (Branch Number)

Financial Institution Number

Bank Account Number

Pre-Authorized Debit Agreement Continued

I/we authorize Child of Mine to withdraw money from my/our bank account in accordance with the monthly amount indicated. I/we understand that this is a Personal Pre-Authorized Debit Agreement (charity donations), as opposed to a Business or Funds Transfer Pre-Authorized Debit Agreement. I/we understand that my/our commitment is for the amount indicated above. I/we understand that I/we have the right to cancel or change this authorization at any time with five business days notice. I/we may obtain a sample cancellation form, or more information on my/our right to cancel this Agreement at my/our financial institution or by visiting www.cdnpay.ca I/we will notify Child of Mine if our personal contact information changes (e.g. name change, address change, etc). I/we will notify Child of Mine if our banking information changes. I/we have certain recourse rights if any debit does not comply with this Agreement. For example, I/we have the right to receive reimbursement for any Pre-Authorized Debit that is not authorized or is not consistent with the terms of this Agreement. To obtain more information on my/our recourse rights I/we may contact my/our financial institution or visit www.cdnpay.ca

Date of Agreement

YYYY

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