Good Samaritan Fund

By entering my own or my Company's routing and account number above and clicking "Make Payment", either as an individual or as an authorized Company representative, I authorize the payment in the amount indicated above to be processed as an electronic funds transfer (EFT) or draft drawn from either my own or the Company's checking or savings account as indicated above and, if necessary, electronic credits to my own or the Company's account to correct erroneous debits. I understand that the processing of the payment will be completed within 1-2 banking days. If the payment returns unpaid, I authorize you or your service provider to collect the payment by EFT(s) or draft(s) drawn from my own or the Company account. I understand that this authorization will remain in full force and effect until I notify you that I wish to revoke it and allow you reasonable opportunity to act on my notice.

I accept these terms, acknowledge these disclosures and authorize this payment on behalf of myself or my Company and further agree, on Company's behalf, that Company shall be bound by the Nacha Rules in effect, both now and as amended from time to time. Please print a copy of this page for your records.