/ Make monthly, semi-monthly, or annual gift payments without having to write a check each time!
To enroll in the electronic funds transfer program, print out and complete this form, sign it and mail it as directed at the bottom or for more information, call Patsy toll–free at 1-800-879-6282 (1-800-TRY-NATA).

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)

Name(s)
(For internal use only) NATA REF #(s)

I (we) hereby authorize the NATA Research & Education Foundation (NATA REF) to initiate debit entries to my (our) bank account indicated below at the financial institution named below to debit same such account.

Financial Institution Name
Branch / Branch Phone Number
City / State / Zip
Routing Number (Obtain from Financial Institution)
Account Number / This is a / checking / savings account

I (we) give permission for NATA Research & Education Foundation to make automatic withdrawals from the account listed above with the following frequency:

Total amount to be debited monthly: $ / quarterly: $
Quarterly: / on the 1st /

OR

/ the 15th (please check one)
Monthly: / on the 1st /

OR

/ the 15th (please check one)
Semi-monthly: / on the 1st /

AND

/ the 15th (check for two debits per month)
Annual amount $ / on the / day of / month

This authorization is to remain in full force and effect until NATA REF has received written notification from me (or either of us) of its termination in such time and in such manner as to afford NATA REF and my financial institution a reasonable opportunity to act on it.

Name(s) / Date
Signature / Signature

NOTE: THE RECEIVER (donor) MAY REVOKE THIS AUTHORIZATION BY NOTIFYING THE ORIGINATOR (NATA RESEARCH & EDUCATION FOUNDATION) IN WRITING AT LEAST 30 DAYS PRIOR TO THE FINAL AUTOMATIC WITHDRAWAL. WRITTEN NOTIFICATION IS REQUIRED.

Return to NATA REF with a voided check or deposit ticket.

Patsy Brown, NATA Research & Education Foundation, 2952 Stemmons Freeway, Dallas, TX 75247