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City of Belgrade 91 E. Central Ave. Belgrade, MT 59714 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] Service Address Utility Acct # AUTOMATED CLEARING HOUSE (ACH) ORIGINATOR AGREEMENT Authorization Agreement for Direct Payments (ACH Debits) I (we) hereby authorize the CITY OF BELGRADE, to debit entries to my (our) account indicated below and the Financial Institution named below, to debit same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. PLEASE ATTACH A COPY OF A VOIDED CHECK TO THIS FORM Customer Bank Bank Address: City/State/Zip: (Bank Routing/Transit Number) (Bank Account Number) Type of Acct: Checking or Savings This authority is to remain in full force and effect until the CITY OF BELGRADE has received written notification from me (or either of us) of its termination in such time and manner as to afford the CITY OF BELGRADE and FLATHEAD BANK a reasonable opportunity to act on it. (print account holder name) (print add’l account holder name) Signature Signature Date Signed Date Signed Please email to [EMAIL REDACTED] June 2023