Fee Sheet

The purpose of this Detail Fee Sheet is to inform you, the Merchant, of fees imposed by Straight Line Source Inc. (hereinafter “SLS”) for services rendered by SLS in connecting you with a Working Capital Company. By signing below, you are authorizing ACH Processing Company to debit your account a one-time payment in the amount indicated below and acknowledging you have read and agreed to the fees detailed herein.

Debit Amount

Bank Name*

City*

State*

Zip Code*

Routing Number*

Account Number*

Company*

DBA*

Street Address*

City*

State*

Zip Code*

Phone*

Please select the corresponding Straight Line Source Funding Specialist*

I do hereby authorize SLS, to initiate a single (debit/credit) entry to (my/our) (Checking Account/Savings Account) as indicated and named on the attached voided check as the depository financial institution for the amount of {typeA24}

If any such debit(s) should be returned NSF, (I/we) authorize the SLS to collect such debit(s) by electronic debit/ACH and subsequently collect a returned debit NSF fee of up to $30.00 per item by electronic debit from my account. This authorization is to remain in full force and effect until SLS has received written notification of its termination by writing to accounting@straightlinesource.com within 10 business days as to afford SLS and SLS’s depository bank a reasonable opportunity to act on it. I am a duly authorized check signer on the financial institution account named on the attached voided check, and authorize all of the above as evidenced by my signature below.

Name*

First NameLast Name

Title

Email*

example@example.com

Signature*

Merchant's Signature*

* IF ACH IS RETURNED OR NOT HONORED IN ANYWAY BY YOUR BANK THERE WILL BE A $35.00 CHARGE FOR EVERY INSTANCE.
* Please sign & return with a copy of a voided check for the account entered above.
* THIS FEE WILL ONLY BE DEBITED UPON THE CONFIRMED FUNDING OF YOUR BUSINESS
THAT WAS SERVICED BY STRAIGHT LINE SOURCE. IN THE EVENT THAT FUNDING DOES NOT OCCUR; THIS FEE WILL NOT BE DEBITED.

Date

ORIGINATION FORM