Capital Payment Form

Authorization

I hereby authorize Capital Realty Group, LLC, hereinafter called "COMPANY", to initiate electronic debit entries to my account indicated below and the financial institution named below, hereinafter called "FINANCIAL INSTITUTION". I acknowledge that that I am an authorized signer or have authority to act on the account and that ACH transactions I authorize to my account must comply with all applicable law.

I accept these terms.*

Yes

Personal Information

Name*

Address*

City*

State*

ZIP Code*

Email*

Bank Information

Financial Institution*

Routing Number*

Confirm Routing Number*

Account Number*

Confirm Account Number*

Payment Information

Amount*

Date/Time*

Drafts will be taken out on the first day of the month on a monthly basis. If the date of the debit falls on a non-banking day, the debit will hit your account on the next banking day and will not hit your account prior to the authorized date.

This authority is to remain in full force and effect until the Lease has concluded or the Company has received written notification from me of its termination in such time and manner as to afford the Company and Financial Institution a reasonable opportunity to act on it.