Financial Account Details

FINANCIAL ACCOUNT DETAILS

Account Holder Information

Entity Type: Individual Corporation LLC Partnership Trust Other:

Bank Account Information

Routing (ABA) Number:    Account Number:    Account Type: Checking Savings

Payment Authorization & Terms

Effective Date:

Payment Method: ACH Debit/Credit Wire Transfer Check Other:

Authorization Type: Recurring One-time   If recurring, Frequency:   Authorized Amount:

By signing below, Account Holder authorizes the payor designated by payor_name to initiate debit and/or credit entries to the bank account identified above for the purposes of paying obligations and adjusting erroneous entries. This authorization constitutes a standing instruction and remains in effect until revoked in writing by Account Holder, which revocation shall be effective only after the payor has had a reasonable opportunity to act on it (not less than 30 days).

Representations, Warranty and Indemnity

Account Holder represents and warrants that all information provided on this form is true, correct and complete; that Account Holder is the owner of the bank account or has the authority to authorize debits/credits on that account; and that Account Holder will notify the payor in writing of any change to the account information at least 10 business days prior to a scheduled transaction. Account Holder agrees to indemnify and hold harmless the payor from any and all claims, losses, costs and expenses (including reasonable attorneys' fees) arising from (a) Account Holder's misrepresentation, negligence or failure to notify of changes, or (b) Account Holder's failure to obtain required authorization from any co-owner or authorized signer.

Limitation of Liability: Except as required by applicable law, the payor's liability for errors or omissions in processing transfers will be limited to correction of the error and, if appropriate, reimbursement of direct losses proved to have resulted directly from the payor's gross negligence or willful misconduct. In no event shall the payor be liable for special, incidental or consequential damages.

Verification and Processing: The payor may verify account information by initiating micro-deposits, requesting a voided check, or using other verification procedures. Account Holder agrees to cooperate with reasonable verification measures. If a debit is returned for insufficient or closed account or for any other reason attributable to Account Holder, Account Holder will be responsible for any fees and for immediate repayment of the amount.

Additional Information & Instructions

Voided check or bank letter attached: Yes Not attached — will provide within

Certification

I certify, under penalty of perjury, that I have the authority to provide the bank account information presented on this form and to authorize debits and credits to this account. I authorize the payor to debit or credit this account in accordance with the instructions and terms set forth above. I understand that this authorization will remain in effect until revoked as described in this form. I acknowledge receipt of and agree to the terms stated herein.

Account Holder attestation: I confirm I am authorized to sign for the account named above

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