DONOR AUTHORIZATION AGREEMENT
Your pledge to the Islamic Center is Tax Deductible.
Tax ID #46-5043358
I (we) hereby authorize Islamic Center of Downtown LA, herein after called Center, to initiate debits (for the purpose of donation) and the bank indicated below, herein after called Bank, to debit the amounts thereof to my (our) checking account indicated below.
Bank Name:
Branch:
Address:
City:
Account No:
State:
ZIP:
This authority to remain in full force until Center or Bank has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Center or Bank a reasonable opportunity to act on it; or until Center or Bank has sent me (or either of US) ten (10) days written notice of Center’s or Bank’s termination of this arrangement.
Name(s):
Date:
Signature:
Signature:
Please enclose a voided check or a deposit slip in this envelope. Thank You.
o (One-time) Check—payable to ICODLA o Cash o Pledge—will fulfill by
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o Monthly Automatic Withdrawal o Bank—include voided check o $10,000 o $5,000 o $2,000 o $1,000 o $500 o $100 o Other $
ISLAMIC CENTER OF DOWNTOWN LA• 852, S.Santee Street Los Angeles CA 90015
3 Personal Information (a donation receipt will be sent to this address)
Name Address City State /Province Zip/Postal Code Home Phone Work Phone
Donation & Pledge Form
I pledge to invest in the Islamic Center MASJID FUND. 1 Payment Method: 2 Amount:
