DEERPATH
38 Main Street
Salamanca, NY 14779

Phone: (800) - 536 - 7014
Fax: (716) - 945 - 3575

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENT (ACH DEBITS)

I (we) hereby authorize DEERPATH hereinafter to initiate debit entries, per our agreement in the contract, to my (our) Checking Account / Savings Account (select one), indicated below at the depository financial institution named below, and to debit the same to such account. I (we) knowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.

Your Banks Name: _________________________________________________

Branch: ________________________________________________________

City: ____________________________

State: ______________________

zip: ___________________

Route Number: _________________________________________
(First 9 digits on bottom left of check)

Account Number: _______________________________________
(Remaining digits not including check number)

Please check one box only.

One time debit

Reccuring debit beginning on ________ of ___________

In the amount of $_____________________

Number of Payments: ______________________________

This authorization is to remain in full force and effect until DEERPATH has received written notification from me (or either of us) of its terminations in such time and in such manner as to afford DEERPATH and DEPOSITORY a resonable opportunity to act on it.

Name(s): __________________________________________
(Please Print)

Date: ___________________________________

Signature: ____________________________________________