This form is to be used for the Alliance 403(b) Retirement Plan and completed by an authorized employer representative.

Employer Bank Information

Employer Name *

Employer Location or Church Code

Employer's Bank Name *

Bank Phone Number

Bank City *

Bank State *

Bank Zip Code *

This account is a *

checking account

savings account

Bank Routing Number (9 digits) *

Bank Account Number * 🛈

Employer Authorization for Automatic Payment

I hereby authorize THE CHRISTIAN AND MISSIONARY ALLIANCE to automatically withdraw monthly contributions from this account as instructed for the 403(b) Retirement Plan. This direct withdrawal will occur between the 7th and 13th day of each month and will appear on the bank statement as a withdrawal.

I understand this authority is to remain in full force and effect until ALLIANCE BENEFITS has received written notification from the employer authorized representative of its termination or change in such manner as to afford THE CHRISTIAN AND MISSIONARY ALLIANCE and employer’s bank reasonable opportunity to act on termination or change request.

Name of Account Holder as Printed on Check *

Authorized Employer's Signature Name *

Employer Title *

Contact Phone Number *

Email Address *

Date * +

Authorized Employer's Signature *

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