United Way of Southwest Colorado

Automatic Payment Form

United Way Automatic Payment is an easy and convenient way to make your monthly pledge payments to United Way of Southwest Colorado. If you have any questions about completing this form, call United Way at 247-9444 for assistance.

To print the Automatic Payment form and mail-in, Click here

To enroll in the United Way Automatic Payment program, complete and submit the following form:

Name on Account

Phone Number

E-mail Address

Name of Financial Institution

Routing Number

Checking

Savings

Account #

Amount to be deducted monthly $

Total Pledge $

By submitting this form, I authorize United Way of Southwest Colorado to charge my pledge payment to my bank account number shown above. I understand that the funds will be withdrawn on the (check one - United Way asks and prefers that automatic payments be made on the 15th or last day of the month)

The 15th of each month

The last business day of each month

Other

(choose your own date)

and that it is my responsibility to ensure that sufficient funds are in my account at that time. Automatic payment will begin in January of the year after the pledge was made.

This authority will remain in effect until December of the year after the pledge was made. Future authorization to continue the Automatic Payment program must be received by United Way in writing. I acknowledge that the origination for ACH transactions to my account must comply with the provisions of the U.S. law.

Clicking the Submit button below is my authorization for United Way to set up Automatica Bank Withdrawl to pay my pledge to United Way.

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