I hereby authorize the Rocky Mountain Synod (RMS) to initiate debit withdrawals from the financial institution named below for Mission Support contributions as directed by the accountholder. No withdrawals will be initiated without the receipt of an authorization form from the accountholder requesting the transfer of funds to RMS. I acknowledge that the origination of these transactions must comply with all applicable laws and regulations.

Further, I agree not to hold the Rocky Mountain Synod responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in directing the withdrawal of funds from my account.

This agreement will remain in effect until RMS receives a written notice of cancellation from me or my financial institution, or until I submit a new Withdrawal Authorization Agreement form to the RMS Finance Department.

NAME OF FINANCIAL INSTITUTION