Automatic Bank Draft
A Hassle Free Way to Support LSU in Shreveport
With an Automatic Bank Draft, you can contribute a monthly donation to the LSUS Foundation automatically through
your checking account. Using an Automatic Bank Draft offers many advantages including spreading out your donation
with 12 equal payments.
How It Works - Each month, we will send a draft request to you bank which will draw the amount of your monthly
donation from your account.
Draft Date - Your account will be drafted on the 10th of every month unless that day falls on a Saturday or Sunday in
which it will be drafted on the following Monday.
Getting Started is Simple - Just complete the form below and return it to us with your voided check. Your drafted
donation will start on the next scheduled bank draft date (see draft date above).
Bank Draft Authorization
I authorize the LSUS Foundation to draw drafts against the bank account listed below in payment of my donation to
the LSUS Foundation. Until this authorization is revoked in writing and received by the LSUS Foundation at least ten
working days prior to the scheduled debiting of my account, the bank is authorized to pay these drafts when drawn
and presented for payment and to charge the same to my account. I further agree to also notify the LSUS Foundation
in writing if I withdraw this authority.
Draft Amount __________________ (*See Chart Below)
Bank Name ____________________________________________________
Bank Account Number - All Numbers from the bottom of Check ___________________________________________
(Please include a voided check to assure accuracy in processing)
If drafting a personal checking account
Your Name _______________________________________________________
Spouses Name (if applicable) _______________________________________________
Your Home Address _____________________________________________________
Your Home Phone _________________________________ Your Home Email
______________________________________
Business Name _________________________________________________________________
Business Address _________________________________________________________
Your Occupation/Title _____________________________________________________________
Business Phone ________________________ Business Fax ______________________ Business Email
_______________________
________ Check here if employed by a company or organization which matches charitable contributions. We will
contact you prior to the end of the year to provide you with a total giving amount for the year. If you choose, you can
then fill out your matching gift form, which normally can be obtained from your human resource department, and
return it to us for processing.
____________________________________
Signature
* Possible Draft Amounts
$8.33 Monthly Draft = $100 Annual Donation
__________________________________________
Date
$20.83 Monthly Draft = $250 Annual Donation
$41.66 Monthly Draft = $500 Annual Donation
$62.50 Monthly Draft = $750 Annual Donation
$83.33 Monthly Draft = $1000 Annual Donation**
$125.00 Monthly Draft = $1500 Annual Donation**
$208.33 Monthly Draft = $2500 Annual Donation**
$416.44 Monthly Draft = $5000 Annual Donation**
$833.33 Monthly Draft = $10000 Annual Donation**
**This donation qualifies for membership in the LSUS Foundation. Please refer to attached membership brochure for
more information.
Be sure to return your voided check with this form to the LSUS Foundation, One University Place,
Shreveport, LA 71115.
ALL INFORMATION IS CONFIDENTIAL