AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS
(ACH DEBITS)

COMPANY NAME: Uyghur American Association, Inc.

COMPANY ID NUMBER: 541853876

I (we) hereby authorize _______________________________, hereinafter called COMPANY, to initiate debit entries to my (our) Checking account indicated below at the depository named below, hereinafter called DEPOSITORY, to debit the same to such account.

DEPOSITORY NAME:

______________________________________________________

BRANCH/OFFICE: ___________________CITY: _________________ STATE: ______

ROUTING NUMBER: ___________________

ACCOUNT NUMBER: __________________

This authorization 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 in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

NAME (S):___________________________________
ID NUMBER: __________________

NAME (S): __________________________________

ID NUMBER: ___________________

SIGNED: ____________________________________

DATE: _________________________

SIGNED: ____________________________________

DATE: _________________________

NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.
PLEASE SEND COPY OF DEPOSIT TICKET OR VOID CHECK

Thank you.

***************bank use only*******************************

Text Box: BANK USE ONLY MASTER AGREEMENT ON FILE: YES NO

COMPANY NAME: __________________________________________________

AGREEMENT DATE: _______________________________

ACCOUNT OFFICER: _______________________________