Pre-Authorized Contribution (PAC) Program Form

Thank you for your interest in the National Federation of the Blind's Pre-Authorized Contribution (PAC) program. This program allows you to contribute to the NFB through recurring monthly donations. These donations can be direct withdrawals from a checking account or charges to a credit card. Please complete the form to start a new monthly donation or update your existing PAC plan. Contact PAC@nfb.org with any questions. Thank you for your generosity and support.

Screen reader note: when accessing the form, please tab through the fields; do not arrow forward.

Note: All fields with an asterisk (*) are required.

PAC ID

NFB Office Use Only

Donor Type*

Individual NFB State Affiliate, Chapter, or Division Private Company

Please select the kind of donor.

Individual Name*

First Name

Last Name

NFB State Affiiate, Chapter, or Division Name*

Company Name*

New or Existing Donor*

New Enrollment Existing Donor

I want to donate this amount each month to the NFB through the NFB PAC program* $

I want to increase my PAC contribution to the NFB by adding this amount to my monthly donation* $

What date do you want your contribution withdrawn each month?*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Email

Credit Card or Bank Account*

Credit Card Bank Account

Select if you want your monthly donation charged to your credit card or debited from your bank account.

Update Credit Card or Bank Account

Credit Card Bank Account

Select if you want to update the credit card your monthly donation is charged to or the bank account to be debited.

Card Type*

Credit Card Number*

Credit Card Expiration Date*

Please enter the two digit month / two digit year, for example 01/22

CVV*

This is a three digit number on the back of a Visa, MasterCard, or Discover card. It is a four digit number on the front of the American Express card.

Is your billing address the same as the address entered above?

Yes No

Billing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Bank Name*

Bank Account Number*

Bank Routing Number*

9 digit number

NFB Affiliate to be Credited*

Division to be Credited (Optional)

I authorize National Federation of the Blind (NFB) to debit the bank account or charge the credit card for the dollar amount I have indicated on this form on the date I indicated in this form. I understand this authorization will remain in effect until I cancel it in writing. I agree to notify NFB in writing of any changes in my account information or termination of this authorization at least five (5) business days prior to the next monthly transaction date. If the payment date falls on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds will be withdrawn from my account on the transaction date I choose. I acknowledge that the origination of ACH or credit card transactions to my account must comply with provisions in U.S. law. I will not dispute National Federation of the Blind’s recurring billing of my bank or credit card so long as the transaction corresponds to the terms indicated in this agreement.

I agree to the above terms*

I Agree

Signature*

Type your name in this field if you agree to the above statement.