Authorization Agreement for Direct Payments (ACH Debits)

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)

COMPANY NAME: Butler-Bremer Mutual Telephone Company COMPANY ID NUMBER: 42-0163690 OR

COMPANY NAME: Shell Rock Communications, Inc. COMPANY ID NUMBER: 26-1182921

I (we) hereby authorize the Butler-Bremer Mutual Telephone Company (DBA: Butler-Bremer Communications) OR–for Shell Rock customers: Shell Rock Communications, Inc. (DBA: Butler-Bremer Communications) hereinafter called COMPANY, to initiate debit entries to my checking or savings account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account.

Depository/Bank Name (required)

Branch Name (required)

City (required)

State (required)

Zip Code (required)

Routing Number (required)

Account Number (required)

Checking Account Savings Account

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

I understand that this payment may not be made if sufficient funds are not available in the account shown above on the scheduled payment date. If sufficient funds are not available in the account, there will be a $15.00 fee. ACH payments are deducted on the 10th of each month unless that date falls on a weekend or holiday, in which case the payment will be deducted the next business day. This date cannot be changed.

NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

First & Last Name(s) (required)

Best Contact Phone Number (required)

Last 4 digits of your SSN (required)

Butler-Bremer Account Number (required)

Please attach a PDF or a JPEG of a voided check or deposit ticket (required):

By checking this box, I/we state that I/we understand and agree to all of the terms and conditions above.