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CREDIT AUTHORIZATION AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS (ACH CREDITS) COMPANY NAME: CITY OF BLACKFOOT COMPANY ID NUMBER: I-826000164 I hereby authorize THE CITY OF BLACKFOOT, hereinafter called COMPANY, to initiate credit entries to my account as indicated below, at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit the same such account. I acknowledge that the origination of ACH transactions to my account must comply with the provision of U.S. Law. Primary Depository Account (Required) Deposit Amount: ☐ Entire Net Pay ☐ Specific Amount Bank Name: Account Type: ☐ Checking ☐ Savings Routing Number: Account Number: Secondary Depository Account (Optional) Deposit Amount: ☐ Remaining Balance ☐ Specific Amount Bank Name: Account Type: ☐ Checking ☐ Savings Routing Number: Account Number: This authorization is to remain in full force and effect until COMPANY has received written notification from me of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. Name Date Signature Employee ID Number (for City of Blackfoot Use Only)