You may also print out this form, complete it, and mail it with a voided check to:
Safe Places Business Office 2607 Lehigh Drive Little Rock, AR 72204
I would like to become a Friend of Safe Places. Please set up a monthly debit from my bank account
for the following amount: 
($10 minimum for direct debits)
($10 minimum for direct debits)FINANCIAL INSTITUTION INFORMATION
AUTHORIZATION / CANCELLATION INFORMATION
I hereby authorize Safe Places: The Center for Healing and Hope, Inc. to initiate direct debit entries to my checking or savings account in the amount indicated above and the Financial Institution above to post to the same account.
This authorization is to remain in force until Safe Places receives written notice of cancellation from me (see below). This notice of cancellation must be received at least 30 days prior to cancellation and in such manner as to afford Safe Places reasonable opportunity to act on it and in no event shall it be effective with respect to entries processed by Safe Places prior to the receipt of the notice of cancellation.
I further authorize Safe Places to initiate such credit entries to said account as may be necessary to correct any erroneous bebit entries previously initiated thereto and I authorize the Financial Institution to accept and to credit or debit the amount of such entries to my account.
All entries initiated hereunder are to be governed in all respects by the rules of the Mid-America Payment Exchange as not or hereafter in effect.
PLEASE ATTACH A VOIDED CHECK.
I hereby cancel the authorization for Safe Places: The Center for Healing and Hope, Inc. to originate Debit
entries to my checking/savings account indicated above, effective on .
(Date)
DIRECT DEBIT AGREEMENT FORM
Please complete this form and mail to:
Safe Places Business Office
2607 Lehigh Drive
Little Rock, AR 72204
