MMS Form

AMERICAN COUNCIL OF THE BLIND
MONTHLY MONETARY SUPPORT PROGRAM

6300 Shingle Creek Parkway, Suite 195
Brooklyn Center, MN 55430
612-332-3242

Please use this form to enroll in our MMS program or change existing information.

New Enrollment:

New Enrollment

If already enrolled, change existing information:

Change Existing Information

Name: *

Address: *

City, State, Zip: *

Telephone: *

E Mail Address: *

If we need to call you, what is the best time to reach you?

What is your preferred method of receiving information?

I AGREE *

I AGREE

I hereby authorize the American Council of the Blind (ACB) to draft the amount indicated on this form, each month on the specified date, from my account or credit card as indicated below, as a contribution to ACB. ACB is further authorized to continue to draft funds, as set forth below, until I instruct ACB to alter or cancel this authorization. As an MMS participant, I understand that I can, at my sole option, designate a portion of my ACB monthly contribution (not to exceed one half) to one state or special interest affiliate of ACB, as designated below.

Please designate the amount you wish to donate each month: * $

Deductions are made the 10th or the 22nd of each month. Please select the date each month you wish the deduction to occur: *

Date to commence: *

Complete this section if you wish to assign a portion of your monthly donation to one state or special interest affiliate. Leave this section blank if you wish to contribute all of your monthly donation to ACB. Affiliate Name:

Amount of your monthly donation you wish to designate (cannot exceed one half of total monthly donation): $

Complete this section if you wish to make your monthly donation via credit card. Credit Card Type:

Credit Card Number:

Expiration Date (month/year):

Name as it appears on the card

Complete this section if you wish to make your monthly donation via ACH deduction. Bank Account Type:

Bank Name:

Bank Address:

Bank City, State, Zip:

Bank Routing Number: (9 digits-usually to the left of account #)

Account Number:

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MMS Form

AMERICAN COUNCIL OF THE BLIND MONTHLY MONETARY SUPPORT PROGRAM

AMERICAN COUNCIL OF THE BLIND
MONTHLY MONETARY SUPPORT PROGRAM