Partners for Paws

for

Roscoes Rescue, Inc.

Savings lives costs money! To help provide for vet care, food, and related costs of caring for our animals while preparing them for their permanent homes, Roscoes needs your help. Now, you can be one of Roscoes Partners for Paws. To do so, you authorize us to debit your bank account on a recurring basis: monthly, quarterly, or annually. The amount per transaction can be as little as $5.00. Just think: for less than the cost of two gallons of gas, you can help save lives, too! I(we) hereby authorize Roscoes Rescue, Inc., hereinafter called Company, to initiate debit entries to my (our) Checking Account / Savings Account (select one) indicated below at the depository financial institution named below, hereinafter called Depository, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. Depository Name _________________________ City ____________________________________ Routing Number (9 digits) ___________________ Branch _______________________ State _______ Zip _________ Account Number _______________

Transaction Amount __________ Frequency _______________ Date _____________ (Example: a Transaction amount of $5 with a frequency of Monthly and a date of 10th would mean that $5 would be debited from your bank account on the 10th of each month) This authorization is to remain in full force and effect until Company has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Company and Depository a reasonable opportunity to act upon it. Name(s) ___________________________________ Date ____________________ Signature(s) __________________________________________ NOTE: All written debit authorizations MUST provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization. All transactions that are returned for insufficient funds will result in this agreement being terminated and I(we) agree to reimburse Roscoes Rescue, Inc. for any resulting fees and expenses. Please include a copy of a voided check or savings account deposit slip with this authorization.