Electronic Funds Transfer Authorization Form 

                                                  Print and mail the completed form to:    
                                                           Lincoln University Foundation. Inc.
                                                           820 Chestnut Street, 301-A Young Hall 
                                                          Jefferson City, Missouri   65101
                                                           (573) 681-5583  or (800) 856-3707

 

I authorize Lincoln University to initiate entries to debit my/our account as follows:

                                                          

Full Name: _______________________________________________   Class Year: n/a

Address: ______________________________________________________________ 

City: _____________________________  State: _________  Zip: ________________ 

Day Phone: ____________________________________________________________

 Withdrawal Amount:

Bi-Monthly (1^st  and 15^th) : ________________________________ 

Monthly (Specify Date) :   _________________________________

One Time Contribution :   __________________________________

Checking Account Number: ________________________________________ 

Savings Account Number: _________________________________________ 

Routing Number: _____________________________________________________ 

Financial institution:   _________________________________________________ 

                                _________________________________________________

Designate my gift to:  

 The Ida Ballard Simon Memorial Scholarship Fund

Please enclose a voided check (not a deposit slip) for account verification. 

This authority is to remain in full effect until Lincoln University has received written notification

of its termination or changes in such time and manner to  afford Lincoln University a reasonable

opportunity to act on it.

 

Signature: _____________________       Date: ___________________