Grayrock Energy ACH Authorization

I (we) hereby authorize Grayrock Energy (“Company”) to initiate credit entries to transfer funds to my (our) checking or savings account at the depository financial institution named below (“Bank”). I (we) agree that ACH transactions authorized herein shall comply with all applicable U.S. law.

Bank Name:

Bank Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Routing Number

must be 9 numbers - no spaces

Account Number

must be 9-12 numbers - no spaces

Type of Bank Account

Owner Name as Listed on Bank Account:

Owner ID Number:

5-digit number found on your remittance or statement from Grayrock Energy)

Contact Name for ACH Remittance:

First NameLast Name

Contact Email for ACH Remittance:

example@example.com

Upload voided check image or bank account verification letter for the account to which funds will be deposited.

I represent that I own oil, gas, and/or mineral interests for which proceeds are distributed by Grayrock Energy. I authorize Grayrock Energy and the financial institution identified above to electronically deposit all future payments into the bank account specified on this form.

I understand that this authorization may take up to sixty (60) business days to become effective. Once processed, this authorization will remain in effect for all future royalty distributions made by Grayrock Energy until I revoke it by providing written notice, signed by me, to the address provided by Grayrock Energy.

If Grayrock Energy deposits funds into my account in error, I authorize Grayrock Energy to instruct my financial institution to debit my account and return the incorrectly deposited funds.

I agree to promptly notify Grayrock Energy of any changes to my banking information. I understand that Grayrock Energy will not be responsible for any loss of interest, delayed payments, or other claims resulting from my failure to provide timely notice of such changes.

I release and hold Grayrock Energy harmless from any loss, claim, damage, expense, or interest arising from the failure of any financial institution to properly process or post electronic deposits.

Grayrock Energy may use and disclose the non-public personal information provided on this form solely for the purpose of facilitating direct deposit of payments. Any non-public personal information shared with financial institutions will be subject to the privacy policies of those institutions. If you choose not to provide the information necessary to establish direct deposit, electronic payment by ACH will not be available for your payments.

Signature

Printed Name

First NameLast Name

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Enter the message as it's shown

Authorization Agreement For Direct Deposits (ACH CREDITS)