Withdrawal Authorization Form

Withdrawal Authorization Form

Please complete this Withdrawal Authorization Form to grant permission for authorized withdrawals from your bank account or financial institution.

Name

    Program/Project Name

    Date

      Withdrawn Amount

      Funds will be used for:

      • I understand that I am responsible for providing receipts/signatures matching this form for the purpose described above, or I will be responsible for returning unused funds advance to me per this agreement.

      Date:

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