Application for:
 Electronic Funds Transfer

I give my bank permission to transfer the following amount from my personal account to pay InterComm, Inc. each month.

Name:  *
Street address:  *
City:  *   State:  *
Zip Code: *               Country:  **
E-Mail address:    Phone:  *

Please use my contribution(s) for the following

InterComm project(s): Amount
A. $
B. $
C. $
Total monthly deduction will be: $

Bank name:  *
Bank phone number:  *
Bank statement account number:  *

Make the monthly deduction from my
 Checking account (enclose a voided blank check)
 Savings account (enclose a savings deposit slip)

I prefer the monthly transfer date of:
 10th 25th account (check one)

to start the month of  

I have read, understand and agree with the information on the bottom of this form and have attached my voided blank check or savings deposit slip to this form.


Signature ______________________________________ Date ____________

* Required information

** If you are submitting this form from a country other than the USA, we will only be able to help you if you are an American citizen.

Print out this page after filling in the form, sign it and mail it with a voided blank check or savings deposit slip to:

 EFT
InterComm, Inc.
P.O. Box 618
Winona Lake, IN 46590

This permission to charge my bank account is the same as if I had personally signed a check to InterComm, Inc. This agreement will remain in effect until:

  1. I write a note or call InterComm, Inc. telling them to end this agreement and they have had a reasonable amount of time to act on it. OR,
  2. InterComm, Inc. or my bank sends me 10 days' written notice that this agreement will end.

In the event of an error, I have the right to tell my bank to reverse any transfer. However, I must tell them in writing within 15 days of the bank statement or within 45 days after the transfer was made.

I understand and agree that my bank is responsible for the accurate and timely posting of my transferred gift(s). In the event of an amount or double posting error, I will handle this problem directly with InterComm, Inc.

Thanks for your support of InterComm, Inc. Through your investments each month you are helping give people worldwide the the opportunity to hear about Jesus Christ  in their own language.