Name of Company: Store More On 4 I hereby authorize Store More On 4 to initiate debit entries to my account indicated below and the financial institution named below. I acknowledge the origination of ACH transactions to my account must comply with the provisions of U.S. law. I request the debit entries to occur in the following mannerWithdraw monthly, on the first day of the month beginning on (date) Withdraw monthly, on the first day of the month beginning on (date) Withdraw monthly, on the day of the month beginning on (date) MM slash DD slash YYYY Customer Name First Customer Address Street Address City State / Province / Region ZIP / Postal Code Email address (to receive payment confirmation) Financial Institution Name First Financial Institution Routing numberAccount numberAccount Type Checking Savings This authority is to remain in full force and effect until Store More On 4 has received written notification from me of its termination in such time and in such manner as to afford Store More On 4 and financial institution a reasonable opportunity to act on it. Customer SignatureDate MM slash DD slash YYYY
