Date: _________________________

To Mary’s Shelter, Inc. , Fredericksburg

I (name) ________________________________________ give Mary’s Shelter, which is a licensed 501(c) not for profit organization in Fredericksburg, VA, the permission to deduct
(amount) _________________________ directly out of my account each month. I have sent a voided out check to Mary’s Shelter for this purpose.

Sincerely,

Name: _____________________________________
Date: _____________________________________