ELECTRONIC FUNDS TRANSFER FORM

____Yes.

Please enroll me in AHEF’s Monthly Giving Fund.I understand that my future gifts will be transferred automatically from my checking account OR my credit card account. (Deductions timed according to sign up date.)

I understand that a record of my gifts will appear on my bank or credit card statement and that I can increase, decrease or suspend giving at any time by sending a signed letter to AHEF. See contact information below.

FOR BANK ACCOUNT DEDUCTIONS:

Please enclose a “VOIDED” check or deposit slip. (Deductions will take place on approximately the 5th or the 20th of each month.)

I authorize my bank to transfer monthly to AHEF the amount below in accordance with the terms and conditions below:

__ $25 __$20 __$15 __$50 __ Other: $______

____ Yes. A check for my first gift is enclosed. Amount: $_______

FOR CREDIT CARD DEDUCTIONS

I authorize my credit card company to transfer monthly to AHEF the amount below in accordance with the terms and conditions below:__ $25 __$20 __$15 __$50 __ Other: $______

(Credit card deductions are timed according to the date of sign up.)

Credit card__Visa __MasterCard __Discover __Amex

Credit card #__________________ Exp. Date______CVV# __ __ __(on back of card)

Name___________________________________________________________

Billing Address_________________________________________________________

City, State, Zip_____________________________________________________________

Phone________________________ E-mail______________________________

Signature________________________________________________________

REQUIRED for Checking Account OR Credit Card deductions

Date Signed_____________________

Check here if this gift is restricted.

Comments__________________________________________________

TERMS AND CONDITIONS:

My authorization to charge my account at my bank will be the same as if I had personallysigned a check to African Health & Education Fund. This authorization will remain in effect until I notify my bank or AHEF in writing that I wish to end

this agreement and my bank or HEFA has had a reasonable time to act upon it. A record of each charge will be included in my

regular bank statement and will serve as my receipt.

AHEF

Tel: (415) 323-5601

Mailing Address:

African Health & Education Fund

530C Alameda Del Prado, #114, Novato, CA 94949

email: info@africanhealth.education