AUTHORIZATION AGREEMENT FOR DIRECT DEBIT

I (we) ____________________________________  hereby authorize FULTON COUNTY CENTER FOR REGIONAL GROWTH, herein after called the COMPANY, to initiate debit entries from my (our)

select one:  ____ Checking     ____ Savings

account indicated below and the Bank named below, and to debit such account for the payment of

$__________________     monthly _______ annually _______one time __________

(please print)

BANK ______________________________________________________________________________

LOCATION _________________________________________________________________________

CITY ___________________________________________ STATE ________ ZIP __________________

TRANSIT/ABA# ________________________________ ACCOUNT# _____________________________

DATE TRANSFER TO BE INITIATED EACH MONTH _________________________________________

This authority is to remain in full force and in effect until the COMPANY has received written notification of its termination in such time and in such manner as to afford the COMPANY and the Bank a reasonable opportunity to act on it (at least 10 business days).

I (we) understand that the COMPANY can only initiate debit and credit entries based upon information provided by myself (ourselves) as the applicant. I (we) agree that the COMPANY has no liability to me (us) if it is unable to make any transfer because of an act of God, mechanical failure or any interruption in communications not within its control. If sufficient funds are not available at the scheduled transfer date, I (we) agree to pay all fees associated with the transfer, including any fees incurred by the COMPANY.

NAME(S) ____________________________________________________________________________

ADDRESS ___________________________________________________________________________

EMAIL ADDRESS ____________________________________________________________________

DATE ___________________________________ SIGNED ___________________________________

SIGNED ____________________________________

*ATTACH A COPY OF A VOIDED CHECK HERE