DebitAuthorizationForm
AUTHORIZATIONFORMFORDIRECTPAYMENTACHDEBITS
CompanyName: REGINAMATER,INC
I(we)herebyauthorize
ReginaMater,Inc.
,hereinaftercalledCOMPANY,toinitiatedebitentries
for:__________________________________________________tomy(our)accountindicatedbelowandthe
financialinstitutionnamedbelow,hereinaftercalledFINANCIALINSTITUTION,todebitthesameto
suchaccount.I(we)acknowledgethattheoriginationofACHtransactionstomy(our)accountmust
complywiththeprovisionsofUSlaw.
FinancialInstitutionName:
Branch:
Address:
TypeofAccount(checkonebelow):
City/State:
Checking:
ZIP:
Savings:
AccountName:
RoutingNumber:
AcctNumber:
Thesenumbersarelocatedonthebottomofyourcheckasfollows:
Family Name
BankDraft
ThisauthorityistoremaininfullforceandeffectuntilCOMPANYhasreceivedwrittennotification
fromme(oreitherofus)ofitsterminationinsuchtimeandmannerastoaffordCOMPANYand
FINANCIALINSTITUTIONareasonableopportunitytoactonit.
Name:
Signature:
Date:
1320E51
st
St·Austin,TX78723·512.524.1799·www.reginamater.us