Please note: this form cannot be submitted online.

  • This page is provided as a convenience, so you can type in your information and then print it out. If you do not have access to a printer, please contact the church bookeeper, to have a form mailed to you.

  • Make sure you include a handwritten signature and date.

  • For added security, please do not type in your account number on the form. Write it on the printout.

  • The button on the bottom of the page cannot be removed, but do not click it.

  • Mail or drop off the form to the office: Bookkeeper, St. Luke's Episcopal Church, 2000 Stover St., Fort Collins, CO 80525

Withdrawal Authorization Form

I hereby authorize St. Luke's Episcopal Church to initiate withdrawals from my account at the financial institution named below, and if deemed necessary, in their sole discretion initiate adjustments for any transactions credited/debited in error.

This authorization is to remain in full force and effect until St. Luke's Episcopal Church has received written notification from me of its termination in such time and in such manner as to afford St. Luke's Episcopal Church and the financial institution named below a reasonable opportunity to act on it. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.

Name of Account Holder *
Name of Account Holder
Phone Number of Account Holder
Phone Number of Account Holder
Please include either a phone number or email address in case we have any questions.
Name of Financial Institution *
Name of Financial Institution
Address of Financial Institution *
Address of Financial Institution
Date (Write in pen on printout)
Date (Write in pen on printout)

Do not use the button.

This form must be submitted on paper, and this page is not secure.