Monthly Monetary Support Program | American Council of the Blind

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Monthly Monetary Support Program

Submitted by admin on Tue, 06/12/2018 - 15:27

Donor Information

Enrollment type:

I am a new enrollee

I am already enrolled and changing existing information

First Name *

Last Name *

Address *

Address 2

City *

State *

Zip

E-mail *

Telephone *

ACB sometimes shares information with other similar organizations for them to contact our supporters. If you prefer that we do not share any of your contact information, please check the statement below.

Please do not share my information with other organizations.

Deductions are made the 10th of the 22nd of each month. Please select the date you wish the deduction to occur each month. (required) *

10th

22nd

Date donation to start *

Amount to donate each month *

$

Please call ACB's finance office at 612-332-3242 to provide credit card or bank information.

Affiliate Information

Complete this section if you wish to assign a portion of your monthly donation to one state or special interest affiliate. Leave this section blank if you wish to contribute all your monthly donation to ACB.

I would like to assign a portion

Affiliate Name:

Amount of your monthly donation you wish to designate (cannot exceed one half of total monthly donation) *

$

Authorization

Authorize to draft: *

I hereby authorize the american Council of the Blind (ACB) to draft the amount indicated on this form, each month on the specified date, from my account or credit card as indicated, as a contribution to ACB.

Continuance to draft: *

ACB is further authorized to continue to draft funds, as indicated herein, until I instruct ACB to alter or cancel this authorization.

Designating a portion: *

Also as an MMS participant, I understand that I can, at my sole option, designate a portion of my ACB monthly contribution (not to exceed on half) to one state or special interest affiliate of ACB, as desgnated herein.

Donor Information

Affiliate Information

Authorization

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