In order to activate automatic funds transfer, please complete this form and mail it to: eServices Corporation 7577 Main St. Ralston, NE 68127 Or, send via fax to: (402) 597-3026 EServices Corporation Automatic Clearing House (ACH) Authorization Organization Name: ___________________________________________________________________ Your Name: ___________________________ email address: _________________________________ Officer Position in Organization: _________________________________________________________ Address of Organization: _______________________________________________________________ City: ______________________________ State: ______________ Zip: _______________________ Day Phone: (_______)__________________ Evening Phone: (_______)____________________ Organization Tax ID Number: ___________________________ BANK INFORMATION Bank Name (Include City/Branch if applicable): ___________________________________________ For help with the following questions concerning bank account information visit the frequently asked questions section of our website at: http://www.eservicescorp.com Bank Account Number: _______________________ ABA Routing Number: ______________________ Bank Name: _________________________________________________________________________ Bank Phone/Address (if on check):________________________________________________________ AGREEMENT By signing below I authorize eServices Corporation to electronically deposit funds using ACH into the above bank account. In addition, I authorize eServices Corporation to withdraw funds using ACH from the above account in order to rectify disputed charges and refunds. Withdrawals will not exceed the disputed deposit amount plus bank processing fees. _______________________________________ _______________________________ Signature Date Please attach a Voided check. If you have any questions please call eServices Corporation at 1-877-866-4848 or email us at ACHService@eServices4U.com .