Central Prairie Co-op

Electronic Funds Transfer Authorization Agreement

I hereby authorize Central Prairie Co-op to initiate debit or credit entries to my account indicated below and the financial

institution named below. I acknowledge that the origination of ACH transactions to my account must comply with the

provisions of U.S. law. This account will be used for all grain payments and account payments unless notified by account

holder.

Today's Date

Month

Day

Year

Name of Account with Central Prairie Co-op

Phone number

Account holder address

Country/Region

Address

City

Zip / Postal code

Email address

Bank name

Bank address

Account holder name

Routing number

Account number

Account type

Checking

Savings

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This authority is to remain in full force and effect until Central Prairie Co-op has received written notification from me of its

termination in such time and manner as to afford Central Prairie Co-op and the above mentioned Financial Institution a

reasonable opportunity to act on it.

Electronic signature

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