eCheck/ACH Recurring Payment Authorization Form
eCheck/ACH Recurring Payment Authorization Form Date: (Campaign Committee) authorizes the DCCC to charge my banking account listed below, starting on the [month, day, year] and on the [day of the month] for each month following through [month, day, year] 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
Monthly Payment Amount: Monthly Payment Start Date: (MM/DD/YYYY). Your account will be charged on the corresponding day of each month after the first charge. Monthly Charge Policy (required) * □ By checking this box I authorize that the above account will be charged by the DCCC for the entered amount on a monthly basis starting on the date entered above. Your account will be charged every month through October 2016. To cancel or to change your monthly charge, contact Kristen Bautz at (202) 485-3413 or [email protected]. □ 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.
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.
This payment authorization is valid and to remain in effect unless I, ___________________________ notify the DCCC of its cancellation by sending written notice by email to Kristen Bautz at [email protected]. ________________________________________ Customer Name / Title Printed Customer Signature
Date
Please attach a voided check below and fax to 202-478-9499 or scan and email to Kristen Bautz 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
Monthly Payment Amount: Monthly Payment Start Date: (MM/DD/YYYY). Your account will be charged on the corresponding day of each month after the first charge. Monthly Charge Policy (required) * □ By checking this box I authorize that the above account will be charged by the DCCC for the entered amount on a monthly basis starting on the date entered above. Your account will be charged every month through October 2016. To cancel or to change your monthly charge, contact Kristen Bautz at (202) 485-3413 or [email protected]. □ 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.
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.
This payment authorization is valid and to remain in effect unless I, ___________________________ notify the DCCC of its cancellation by sending written notice by email to Kristen Bautz at [email protected]. ________________________________________ Customer Name / Title Printed Customer Signature
Date
Please attach a voided check below and fax to 202-478-9499 or scan and email to Kristen Bautz 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.
