Islamic Society of Gastonia

P.O. Box # 550505, Gastonia, NC 28055

704-824-7994

PLEDGE & AUTOMATIC DEDUCTION FORM

Authorization for Electronic Debit Transfer

I hereby authorize Islamic Society of Gastonia to charge my account at the bank on my attached voided check on or about fifth(5th) day of each month. This electronic debit is for operating expenses of the Masjid. I agree to maintain sufficient collected funds in my account to cover any such debit upon presentation.

This authorization is to remain in full effect until the Masjid receives a ten (10) days written notification from me or my duly authorized representative or unless the Masjid elects to discontinue this method of collecting donations.

Name_____________________ Signature of Donor____________________

Monthly debit $___________________

Address ______________________________________________________

_____________________________________________________________

Phone __________________________

PLEASE ATTACH YOUR VOIDED CHECK OR DEPOSIT SLIP AS SHOWN BY EXAMPLE

Please remember that you can cancel your monthly pledge any time for whatever reason. All you need to do is to just inform the Masjid in writing and your wish will be carried out promptly and without question, Insha-Allah. May Allah reward you (Ameen).