Transport Funding

ACH Authorization

The undersigned ("CUSTOMER") hereby authorizes TRANSPORT FUNDING, LLC, and its affiliates and subsidiaries ("COMPANY"),
to initiate automatic debit entries (withdrawals from) the:
At the Financial Institution named below ("DEPOSITORY"), and to automatically withdraw funds from such account each month. The undersigned understands that the amounts withdrawn from this account may vary each month according to the terms of the lease, loan, service contract, or other form of agreement. CUSTOMER acknowledges that the origination of ACH transactions to CUSTOMER’S account must comply with all provisions of U.S. law and that the COMPANY is not obligated to originate any such transactions for any reason COMPANY may determine, including, but not limited to, any event of default under the terms of any loan, lease or agreement, or the prior failure of any such ACH transaction to clear.
Financial Institution Name:  
City: State: Zip:  
Routing Number:  
Account Number:
This authorization is to remain in full force and effect until COMPANY has received written notification from the undersigned (if more than one, any one of the undersigned) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
The CUSTOMER or authorized signer for CUSTOMER must complete:
Customer Name:
Phone: (Format: 123-456-7890 or 1234567890)  
Tax ID/SSN: (Format: 12-3456789, 123-45-6789 or 123456789)  
Loan Number: (Format: 506-#######-### or 506##########)  
Payment Amount:  
Payment Begin Date: (Format: mm/dd/yyyy)  
Send completed form to Transport Funding LLC, 8717 West 110th Street, Suite 700, Overland Park, KS 66210
Authorized Signature: Date: (Format: MM/dd/yyyy)  
  Customer Signature (Type name, required)