Direct Deposit

Authorization for Automatic Deposits and Debits

DIRECT DEPOSIT

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First Name

Last Name

hereby authorize e3 Personnel to deposit the amount of each of my payments directly into my checking or savings account indicated below in the Deposit Instructions and to make any such withdrawals directly from my account or accounts as are necessary to correct any incorrect deposit by the Company under this Authorization. I further hereby authorize and instruct my Bank/Credit Union to accept such automatic deposits to or withdrawals from my account or accounts by the Company and to cause my account or accounts to be automatically credited or debited (as the case may be) in the amount of such deposits or withdrawals by the Company without any responsibility for correctness of any such deposit or withdrawal.

Initial

Deposit the full amount of each of my payments to my account:

Account Type

Attach a voided check

Attach a pre printed deposit slip

Bank/Credit Union Name

Bank Street Address:

Bank City, State & Zip Code

Bank/Credit Union Telephone

Bank / Credit Union Account number:

ABA routing number from your bank / Credit Union

I understand that I can cancel this authorization at any time. To cancel, I must give written notice to both the Company and the Bank. My cancellation will become effective as to the Company when the Company receives my notice of cancellation and has had a reasonable period of time upon which to act on it. Any automatic deposits to or withdrawals from my account or accounts by the Company up until that time will be authorized by this authorization. My cancellation of this authorization will become effective as to the credits or debits made to my account or accounts by the Bank when the Bank receives my notice of cancellation and has had a reasonable period of time upon which to act on it. Any automatic credits or debits made to my account or accounts by the Bank up until that time will be authorized by this authorization. I further understand that all automatic deposits and credits to or withdrawals and debits from my account or accounts under this authorization will be subject to all rules regulations, agreements and disclosure statements of the Company and the Bank governing accounts and preauthorized transfers to and from accounts. I understand pay stubs are mailed by request. Call our office to place request. By signing, I acknowledge receiving and agree to each and every term, condition, and provision of the Deposit and Debit Agreement (including, without limitation, the ARBITRATION AND WAIVER OF JURY TRIAL provisions for changing the terms there of and related disclosures for this account. I hereby state that I received a completed copy of this authorization on the date I signed this authorization.

Name

Signature

Date

Direct Deposit

DIRECT DEPOSIT

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