Automatic Bank Draft

Please print this page. Complete the form, sign it, and mail it to:

University of Virginia Fund
Jefferson Trust Gift
P.O. Box 400314
Charlottesville, VA 22904-4314

If you have questions, please call (434) 243-9000

You may expect your gift deductions to begin within 30-45 days after this authorization has been processed and they will take place on or about the 10th day of each month. Your monthly bank statement will itemize this draft when it occurs. Gift receipt(s) will be issued from The Jefferson Trust.

Thank you for your generosity!

BIOGRAPHICAL INFORMATION

Your name:______________________________________________

Home Address:___________________________________________

City:_________________ State:_______ Zip:_______________

Home Phone:_____________ Business Phone:___________________

E-mail Address:__________________________

BANK INFORMATION

I/We authorize the University of Virginia Fund to initiate debit entries to my/our bank account established at the financial institution indicated below:

Financial Institution:__________________________________________

Address/Branch Office:_________________________________________

City and State________________________________________________

Transit/ABA Number_______________ Account Number_______________

Type of Account: Checking Savings

(YOU MUST ATTACH A VOIDED CHECK OR DEPOSIT SLIP)

GIFT DESIGNATION

I/We wish to make monthly gift payments of $_____________ posting to my/our account.

For a period of: (please check one)
6 months 12 months 24 months 36 months Until I request you stop

For recognition in various Gift Clubs, the University operates on a fiscal year running from July 1 to June 30. Each monthly gift payment will be recognized in the fiscal year in which it is received.

ACCREDITATION

Should your spouse also receive credit for these gifts? Yes No

MATCHING GIFTS

Many employees offer a matching gift program that can double or even triple your gift, and you will receive credit for your employer’s contribution. To find out if your company or your spouse’s company matches gifts, contact the company’s human resources department or check this online company search.

Does your company match gifts? Yes No

Company Name:_______________________________________

AUTHORIZATION

This authorization will remain in full force and effect until the University of Virginia Fund has received written notification from me (or either of us) of its modification or termination in such time and in such manner as to afford the University of Virginia Fund a reasonable opportunity to act on it.

_____________________________
Signature

_____________________________
Signature, if Joint Account