To donate by mail to Children''s Home Society of Washington, please print, fill out, and mail this form to:

Fund Development Office
Children's Home Society of Washington
P.O. Box 15190
Seattle, WA 98115

Yes! I'd like to sign up for Easy Give!

Contribution amount collected (check one):

$_____________ Monthly (the 1st OR 15th - circle one)
$ _____________  Quarterly (the 1st of the month)

Date contributions are to begin: ______________________

Name on Account (please print): _____________________
Address: _______________________________________
City: ___________________State: ______ZIP: _________

Please accept my ongoing contribution from my:

Checking account (attach a voided check)
Savings account (attach a savings deposit slip) Routing # (Between these symbols |:|:): _______________________

Account # : _____________________________________

I authorize Children's Home Society of Washington to process debit entries to my account. I have attached a voided check or savings deposit slip. This authority will remain in effect until I give reasonable notification to terminate this authorization.

Authorized signature on my account: ___________________
Date:_______________
Please attach voided check or savings deposit slip

FOR OFFICE USE ONLY

Contributor ID#:

ES2901