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North Lane Technologies, Inc. *** E. North Lane, Suite 5040 Conshohocken, PA 19428 www.northlane.com ACH WITHDRAWAL FORM

This ACH (Automated Clearing House) form is needed to transfer funds from your North Lane card to your bank account. Please allow 2-3 business days for funds to clear once form has been processed. Please either FAX 570-***-****) or MAIL to:

North Lane

ACH Withdrawal Department

P.O. Box 284

Conshohocken, PA 19428

North Lane Card Number:

(Name/Authorized signer on the Bank account)

First Name: MI Last Name: Phone No. (in case follow up is needed): Name of Financial Institution: Bank Routing Number: A 9-digit number located in the lower left part of the check between the I: I: symbols Bank Account Number: Appears before the “II” symbol on a paper check.

Type of Account: Savings Checking

Amount: $

Please include VOIDED CHECK or *BANK LETTER.

ACH Form cannot be processed unless of the above is included. Bank letter must be written on bank letterhead and include: cardholder name, routing number, bank account number. Please Note: A single ACH Withdrawal cannot exceed $9,999. If larger amounts than $9,999 are required, please submit additional ACH Withdrawal requests.

Fees: The fee for a rejected transaction is $2.00 and will be deducted from the amount returned to your North Lane Prepaid Card.

With this signature, I authorize North Lane to complete transfers between my North Lane Prepaid Card and the indicated payment account, and give North Lane the authority to verify that I am the owner of the payment account. North Lane reserves the right to reject or cancel any payment request for any reason. SIGNATURE DATE

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