BRETHREN HOUSING ASSOCIATION

Recurring Donation Initiation Form

A recurring donation is a convenient way to give. It allows you to give as your monthly budget allows. And giving an affordable amount on a regular basis can add up. Just $25 given monthly adds up to $300 in a year, and $100 per month becomes $1,200 over one year. You can initiate a recurring donation in two ways:

· Contact your financial institution. You may be able to set up a recurring donation to BHA through your bank, credit union or other financial institution. Contact your institution to set up the amount and frequency you desire. It is also helpful if you contact our office to alert us to this arrangement so we can thank you appropriately.

· Donate directly through BHA's payment processor. Fill out this form and mail it to BHA. You can initiate a recurring donation for the period of your choice, after which time you will have the option to renew it. Please note: you may discontinue your recurring donation at any time with 30 days written notice.

Your Contact Information

Name: ______________________________________________________________________________________

Address: ________________________________________________________________________________________

City:________________________________ State: ______________________________ Postal Code:_____________

Telephone: _________________________ E-mail: ______________________________________________________

Donation Details (Choose One)

Weekly Payments	Monthly Payments
Amount of Individual Payment: $__________ Day of week to process payment: _____________ Stop Recurrence After*: q 52 Payments (One Year) q 104 Payments (Two Years) q 156 Payments (Three Years) q Other # of Payments: _________ Date To Process First Payment (example: Jan. 5, 2011): ___________________________	Amount of Individual Payment: $__________ Day of month to process payment, between 1 and 28: ____ Stop Recurrence After*: q 12 Payments (One Year) q 24 Payments (Two Years) q 36 Payments (Three Years) q Other # of Payments: _________ Date To Process First Payment (example: Jan. 5, 2011): ___________________________

* At the end of this period, you will be contacted and asked whether you desire to initiate a new recurring donation.

Method of Payment (Choose One)

By Credit Card	By Electronic Check
Card Type: q Visa q Mastercard q Discover q American Express Card Number: _______________________________ Expiration Date (month/year): ________/__________	Bank Name: ___________________________________ Routing Number: _______________________________ Account Number: _______________________________ Account Type: q Personal q Business

I would like a tax receipt:

q Each time a payment is processed q Only once, at the end of the calendar year

By signing below you are authorizing Brethren Housing Association to initiate a recurring donation via the method, in the amount, at the frequency, and for the duration described above. You may cancel the recurrence of this donation at any time with 30 days written notice to BHA, 219 Hummel Street, Harrisburg, PA 17104.

_______________________________________ __________________  

Signature Date

Thank you for your recurring support! Please mail your completed form to:

BHA, 219 Hummel Street, Harrisburg, PA 17104

The official registration and financial information of Brethren Housing Association may be obtained from the Pennsylvania

Department of State by calling toll free, within Pennsylvania, (800) 732-0999. Registration does not imply endorsement.