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Monthly Giving

Please contact Sidney Hardgrave at sidneyh@independenceinc.org  to arrange automatic payments of monthly donations or print out the form below and send it along with a voided check to:  

Independence, Inc.
Attn:  Annual Support
2001 Haskell Avenue
Lawrence, KS  66046
 

Name:________________________________________________________

Address:______________________________________________________

City:_______________________  State:_________  Zip:________________

Phone (Daytime): _____________________  (Evening): ____________________

 
I, ____________________________, hereby authorize Independence, Inc. to 
                    (print name)

deduct $____________ monthly from my checking account :

_________________________, drawn on ___________________________
                  (account number)                                                (name of bank)

beginning on the _________ day of ___________________, 200____.

________________________________                        _______________________
Signature                                                                                                              Date