ACH Debit Blocking Service Guide l JPMORGAN …



ACH Debit Blocking Service Setup Form l JPMORGAN CHASE BANK, N.A.

To ensure accuracy, please complete the form by typing in the information - do not hand-write the information on the form

V2.6_04_11_07

New Account Modify/Add Company ID Delete Accounts (section 5) Delete Company ID (section 5)

1. All ACH Debits Blocked: (New accounts or setups only)

|Customer Account Number | |State/Bank Number/ABA | |Customer Account Number | |State/Bank Number/ABA |

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2. All ACH Debits Blocked with the Following Exceptions: (New accounts and Modifications)

|Customer Account Number | |State/Bank Number/ABA | |Allowable Company IDs | | |

| | | | | | |Max Dollar Amt of a Single ACH Debit |

|1061332 | | | |1020401225 | |100.00 |

|1061332 | | | |6943404276 | |100.00 |

|1061332 | | | |1830417755 | |100.00 |

|1061332 | | | |1911144442 | |100.00 |

|1061332 | | | |7911906058 | |100.00 |

|1061332 | | | |4770156161 | |100.00 |

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3. Allow all ACH Debits except those exceeding the following amounts: (New accounts and Modifications)

|Customer Account Number | |State/Bank Number/ABA | |Maximum Debit Dollar Amount |

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4. Allow all ACH Debits except those bearing the following Company IDs: (New accounts and Modifications)

|Customer Account Number | |State/Bank Number/ABA | |Non-Allowable Company IDs |

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5. Delete the following accounts from Debit Blocking: (Deletions only)

|Customer Account Number | |State/Bank Number/ABA | |Customer Account Number | |State/Bank Number/ABA |

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6. Delete an Allowable or Blocked Company ID: (Modifications only)

|Customer Account Number | |State/Bank Number/ABA | |Company ID | |Type of Filter |

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The following are the names and telephone numbers of authorized employees of the Customer who may be contacted in connection with ACH Debit blocking:

|Name | |Telephone Number | |

|Jennifer Kent | |310-815-5336 | |

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Billing is at the individual account level. Indicate if you would prefer to have a single account billed for all Debit Blocking Services.

|Customer Account Number | |State/Bank Number/ABA (REQUIRED) |

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This form should be delivered to JPMorgan Chase Bank, N.A., c/o JPMorgan Treasury & Technology Services [

|Print Name of Customer | |

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|Authorized Signature | |

|Print Name & Title of Signer | |

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|Authorized Signature | |

|Print Name & Title of Signer | |

|Date | |

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|For Bank Use Only: |

| Signature Verification Completed by:      | |

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|Signature: |Date:      |

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