Wednesday, 08 September 2010
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EFT Funding Form
First Name
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Middle Initial
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Last Name
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Street Address
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City
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State
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Zip Code
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Phone Number (with area code)
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E-mail Address
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9 digit routing number
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Amount to be debited each month
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If you would like to contribute a different amount please contact us at funding@lotwem.org
Day of the month to be debited
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1643 N. Alpine Rd.,
Suite 104 PMB 173
Rockford, Illinois USA 61107
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