COA IIN:________________

Authorization Agreement for Direct Payment

Yes, I want to support your work with the orphans in Cambodia! Please debit my chosen account on a monthly basis.

I hereby authorize Cambodian Orphan Aid / Bykota Ministries, hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account or Savings Account as indicated and to debit the same to such account. I (we) acknowledge the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Financial Institution ________________________________ Branch__________________

City ___________________________________ State____________ Zip_______________

Routing Number ___________________________ Account Number__________________

This authorization is to remain in effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Printed Name ______________________________________________________________

Signature ___________________________________ Date _________________________

Date of Withdrawal ______________Amount of Withdrawal ____________ Initial ______

Please attach copy of voided check to this form
Mail to Cambodian Orphan Aid; PO Box 535, Carthage, MO 64836