Empire ATM ACH Authorization Release

Customer

(“Customer”) authorizes Columbus Data Services, (“CDS”) to initiate ACH transfer entries and to debit and/or credit the account identified herein for all Processing Services. CDS shall have the right to credit or debit account, on behalf of the Customer, for settlement of transactions, settlement error corrections, transaction adjustments and any amounts or fees due CDS by Customer. Customer agrees to keep account funded to the extent needed to reasonably support transaction adjustments. All shortages and adjustments are the full responsibility of the Customer. Customer agrees to comply with all electronic fund transfer regulations, requirements, and rules. This Authorization shall remain in effect unless canceled by Customer by providing written notice of cancellation to CDS and after such time as all settlements and adjustments have been processed/cleared through the account. Any debits and credits pursuant to this Authorization will be effected through the Federal Reserve System automated clearing house (ACH) system.

Settlement Disputes

Customer shall audit and balance the data contained in the periodic statements and reports provided by CDS and shall promptly, but in no event more than 30 days after the date of the disputed item, notify CDS in writing (the “Notice Date”) of any disputed item or items on such periodic statements and reports. If CDS determines that the disputed item was credited or debited in error by CDS, CDS shall correct the error. Notwithstanding, CDS shall not be liable for any recovery, reimbursement or otherwise of
any amounts over 30 days from the Notice Date. CDS will, however, use its commercially reasonable efforts to recover any amounts over such 30-day period. CDS shall not be liable for any damages, interest or costs associated with the error other than correcting the error. The undersigned represents and warrants to CDS that the person executing the Authorization is an authorized signatory on the Account referenced below and all information regarding the Account and the Account Holder is true and correct.

Name

First Last

Email*

Electronic Signature*

I agree

This form MUST be accompanied by a pre-printed voided check or a letter from the bank to which the funds are settling referencing the Customer’s name, routing number and account number. The information on the check or bank form must match the information provided below. Forms submitted without all fields on this document completed will not be processed.

Routing/Transit Number (9 digits)

These numbers are printed on the bottom of your check. Routing number is before the Account number.

Account Number

These numbers are printed on the bottom of your check. Account number is after the Routing number.

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