LOFT Community Services Logo

Monthly Giving Authorization Form

Fill out and print the following form to mail or fax it to LOFT.

Name:
Address:
Street name and number:
Apt. (if applicable):
City:
Province:
Postal Code:
Telephone:

Dear Development Office at LOFT,

I wish to make a Monthly Gift in the amount of $to LOFT Community Services, beginning on the 15th of , 200, and continuing on the same day every month until I notify you otherwise.

Please direct my donation to:
Support all the work of LOFT
Support a specific program within LOFT (please specify)

I hereby authorize LOFT to arrange for the following methdo of automatic monthly payment (choose one of the two following options):

1 - Pre-Authorized Chequing
Name of Bank:
Branch Address:
(please enclose a cheque marked "Void" so that we can set up the transaction)

2 - Monthly Credit Card Payment
Visa
Mastercard
Card Number:
Expiry Date: Month Day Year
Nmae as it appears on card:
Signature: _______________________________________________
Date: _______________________
Facsimile:

416-979-3028

 Mail:

LOFT Community Services
205 Richmond Street West, Suite 301
Toronto, Ontario
M5V 1V3