eCheck/ACH One-time Payment Authorization Form
eCheck/ACH One-time Payment Authorization Form Date: ________________________(Campaign Committee) authorizes the DCCC to charge my banking account listed below, for the amount of _______________________[Monthly Payment Amount] for DCCC Member Dues. Campaign Information: Member Name: Campaign Address: FEC ID: Campaign Contact:
Campaign Name: City:
State:
Phone:
Email:
Billing Information Bank Name: Campaign Name as Listed on Bank Account: Bank Account Type: □ Checking □ Savings Bank ABA Routing Number: Bank Account Number:
ZIP:
□ Business Checking
Payment Amount: One-time Charge Policy (required) * □ Please check this box to confirm that the following policy is understood: For the purposes of FEC reporting, this constitutes an Unlimited Transfer to a National Party Committee.
________________________________________ Customer Name / Title Printed Customer Signature
Date
Federal law requires us to use best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions exceed $200 in a calendar year. Paid for by the Democratic Congressional Campaign Committee. 430 South Capitol Street, SE • Washington, DC 20003 • (202) 863-1500 • www.dccc.org Not authorized by any candidate or candidate’s committee Contributions or gifts to the Democratic Congressional Campaign Committee are not tax deductible. Contributions from foreign nationals and corporations are not permitted.
Please attach a voided check below and fax to 202-478-9499 or scan and email to Courtney Lee-Ashley at [email protected]. Payments and orders cannot be placed until the completed form is received.
Voided check
Federal law requires us to use best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions exceed $200 in a calendar year. Paid for by the Democratic Congressional Campaign Committee. 430 South Capitol Street, SE • Washington, DC 20003 • (202) 863-1500 • www.dccc.org Not authorized by any candidate or candidate’s committee Contributions or gifts to the Democratic Congressional Campaign Committee are not tax deductible. Contributions from foreign nationals and corporations are not permitted.
Campaign Name: City:
State:
Phone:
Email:
Billing Information Bank Name: Campaign Name as Listed on Bank Account: Bank Account Type: □ Checking □ Savings Bank ABA Routing Number: Bank Account Number:
ZIP:
□ Business Checking
Payment Amount: One-time Charge Policy (required) * □ Please check this box to confirm that the following policy is understood: For the purposes of FEC reporting, this constitutes an Unlimited Transfer to a National Party Committee.
________________________________________ Customer Name / Title Printed Customer Signature
Date
Federal law requires us to use best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions exceed $200 in a calendar year. Paid for by the Democratic Congressional Campaign Committee. 430 South Capitol Street, SE • Washington, DC 20003 • (202) 863-1500 • www.dccc.org Not authorized by any candidate or candidate’s committee Contributions or gifts to the Democratic Congressional Campaign Committee are not tax deductible. Contributions from foreign nationals and corporations are not permitted.
Please attach a voided check below and fax to 202-478-9499 or scan and email to Courtney Lee-Ashley at [email protected]. Payments and orders cannot be placed until the completed form is received.
Voided check
Federal law requires us to use best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions exceed $200 in a calendar year. Paid for by the Democratic Congressional Campaign Committee. 430 South Capitol Street, SE • Washington, DC 20003 • (202) 863-1500 • www.dccc.org Not authorized by any candidate or candidate’s committee Contributions or gifts to the Democratic Congressional Campaign Committee are not tax deductible. Contributions from foreign nationals and corporations are not permitted.
