Yes, I want to contribute regularly to WBVN through the automatic fund transfer plan. My voided check is enclosed. Deduct the amount indicated each month on the day shown. This authorization is the same as if I personally mailed a check. It remains in effect until I notify WBVN that I wish to discontinue contributions. WBVN is registered and authorized by the State of Illinois and the Internal Revenue Service as a non-profit organization. All gifts to WBVN are tax deductible.

Name:_________________________________(print)

Address:_______________________________

City:__________________________________ State:____________ Zip:________

Phone:____________________

WBVN Identification #, if you know it, (4 digit number found on the front of your Newsletter label):_________

I prefer for the transfer to take place on the 3rd______ or 18th______ of each month. (check one)

Signature:_______________________________ date:_______________________

Mail this form with a voided check to: WBVN, P.O. Box 1126, Marion, IL. 62959