AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS (ACH CREDITS)



Piedmont Management Associates, LLC

1389 Peachtree Street NE Suite 350

Atlanta, GA 30309

404-872-8468

Fax: 404-724-0189

Monthly Association Fee Deduction (Automatic Draft)

Authorization Form

Association Name: ______________________________________

I (we) hereby authorize Piedmont Management Associates, LLC, as the banking representative for my homeowners/condo association, to debit my checking account indicated below and the bank named below, hereinafter called the Bank Name, to accept and process the request for my monthly association fee. This process will be done on the 5th of each new period. I understand that charges in my association fee will be adjusted automatically for future payments.

In order to begin this process, please complete the following information:

|BANK NAME | |BANK OFFICE | |

| | | | | | |

|CITY | |STATE | |ZIP | |

| | | | |

|ROUTING & TRANSIT # | |ACCOUNT # | |

(These nine numbers are located on the lower left hand side of your check)

ACCOUNT NAME (S) _____________________________________________________________________

E-MAIL ADDRESS: (used for confirmation & notification)______________________________________

DAYTIME PHONE NUMBER: _____________________________________________________________

This authority is to remain in full force and effect until Piedmont Management Associates; LLC has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Piedmont Management Associates, LLC a reasonable opportunity to act on it.

Property

|NAME (S) | |Address | |

|SIGNATURE | |DATE | |

|SIGNATURE | |DATE | |

**Please attach a voided check if a checking account is selected.**

FOR COMPANY USE ONLY

Date received _____________________________________

Processed by _____________________________________

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