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Patagon:aHealtb Sales Agreement <br /> ACH PREAUTHORIZED PAYMENTS (DEBITS) <br /> Starting from date / /201_, I hereby authorize Patagonia Health Inc to initiate debit enlries or <br /> such adjusting entries, either debit or credit which are necessary for corrections, to my(diet" ' or <br /> sgmngs account indicated below and the financial institution named belo to credit(or debit) <br /> the same to such account. <br /> 15 u <br /> FINANeM INSTIT'L11,10N NAB CffY, STATE <br /> ()(n 16 a 6 I'LO-1 14 (4 0 Q ,3 <br /> TRANS fMOU MG MJW� t ACCOUNT NUhMER <br /> I understand that this ACH authorization will be in effect until I notify my financial institution in writing that I no longer <br /> desire ACH,allowing it reasonable time to act on my notification. I also understand that if corrections in the debit amount <br /> are necessary,it may involve an adjustment(credit or debit)to my account. <br /> I have the right to stop payment of a debit entry by notifying my financial institution before the account is charged. If an <br /> erroneous debit entry is charged against my account,I have the right to have the amount of the entry credited to my account <br /> by my financial institution. I agree to give my financial institution a written notice identifying the entry,stating that it is in <br /> error,and requesting credit back to my account. I will provide this written notice within 45 days after posting. <br /> NAME <br /> vo. n <br /> PRAcIV�E <br /> wa'� /�' t <br /> SIGNA'nM DATE <br /> Confidential Page 9 <br />