Get It Done Club

I hereby authorize my bank to charge my account each month and pay to Iowa Citizens for Community Improvement the amount shown below in accordance with the terms and conditions outlined.

Amount Per Month $________ ($5 Minimum) On ____1st or ____15th Day

Checking Account #___________________Routing #____________________

NAME__________________________________________________________

ADDRESS_______________________________________________________

SIGNATURE___________________________________DATE_____________

I (we) acknowledge the origination of ACH transactions to my (our) account must comply with provisions of U.S. law. This authorization shall remain in full force and effect until written notification from me of its termination has been received by Iowa Citizens for Community Improvement and Iowa Citizens for Community Improvement has had a reasonable opportunity to act upon such notice of termination.

___ Please don't print my (our) name(s), I (we) prefer to remain anonymous

Please include a check for your first installment and mail to Iowa CCI:
2001 Forest Avenue . Des Moines, IA 50311