2012-169 EDC - Buxton Corporation for Analysis Services $56,000

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111111 Orange County, NC Overview ACH Payment Authorization Form Please sign and complete this form to authorize Buxton to make ACH debits from your bank account By signing this form you give Buxton permission to debit your account the total amount due as indicated by the contractual agreement. This is permission for transactions to be debited on the 15th of each month as indicated by the agreed upon payment terms,and does not provide authorization for any additional unrelated debits or credits to your account. For your initial setup a completed authorization form must be submitted by the loth to have your account debited by the 15th of that same month. If the 15th falls on a weekend payment will be processed the next business day. Written cancellation of this agreement must be submitted to our office within 5 business days of the next scheduled debit. Please complete the information below: authorizes Buxton to charge its bank account indicated below (Customer Name) the total amount due as indicated on my Buxton invoice on or after the 15th of each month. Name Billing Address Phone# City,State,Zip Email Name on Account: Bank Name: Bank Account Number: Bank Routing#: Bank City/State: This Bank Account is Enabled for ACH Transactions E Yes C No SIGNATURE DATE NAME (printed) I certify that I am an authorized user of the bank account as stated above and that I have the authority to authorize this payment on the accounts behalf.I understand that because this is an electronic transaction,these funds may be withdrawn from the account as soon as the above noted transaction date. In the case the transaction is returned for Non Sufficient Funds(NSF)I agree to an additional$25.00 charge for each attempt returned NSF,which will be added to your Buxton account balance.I have certified that the above bank account is enabled for ACH transactions,and agree to reimburse Buxton for all penalties and fees incurred as a result of my bank rejecting ACH debits or credits as a result of the account not being properly configured for ACH transactions.Both parties agree to be bound by NACHA Operating Rules as they pertain to this transaction.I acknowledge that the origination of ACH transactions to its account must comply with the provisions of U.S.law. I agree not to dispute this transaction with my bank or Buxton provided the transaction corresponds to the terms indicated in this authorization form. 2651 South Polaris Drive • Fort Worth,TX 76137 • Phone:(817)332-3681 • Fax:(817)332-3686 • buxtonco.com