Download ACH AUTHORIZATION FORM I, the undersigned hereby agree that

ACH AUTHORIZATION FORM
I, the undersigned hereby agree that HighMark Energy Operating, LLC may reverse any electronic payment that is determined to be
duplicate or made in error. I further agree that authorization of EFT (electronic funds transfer) as evidenced by the signature below
amends my existing payment instructions and such authorization will remain in effect until otherwise cancelled by way of written
notification to HighMark Energy Operating, LLC. I also acknowledge that I may change any portion of the information provided below by
giving at least thirty (30) days written notice. The 30 day notice begins at such time the notice is received and date stamped by HighMark
Energy Operating, LLC. I agree that HighMark Energy Operating, LLC will not be liable for any interest or other claim arising as a result
of Owner’s failure to give such notice.
I hereby agree to the terms stipulated herein, certify that the depository information listed below is accurate and authorize HighMark
Energy Operating, LLC to issue payments to me electronically via EFT. Please allow up to two revenue check cycles for this process
to be completed.
Owner Number:
___________
Account Name:
______
_______________________
Address:
_________________________________
City, State, ZIP
_________________________________
Last 4 digits of Tax ID or Social Security Number: ___________
Account Type: __________Checking _________Savings
Name of Bank: ______________________________________
Bank Account Number: ________________________________
Routing Number: ____________________________________
_____ New Request _____ Change Existing Set-Up
Signature: ___________________________________
Print Name: __________________________________
Title: ________________________________________
(E.G., “Owner”, “Trustee” or “Officer of Company”)
Daytime Phone Number: ________________________
E-mail: ______________________________________
Date: _______________
Please check the box below to indicate that you acknowledge that in signing up for EFT/ACH you accept that your check revenue detail
will only be available electronically at www.energylink.com. Should you not check the box below, the EFT/ACH form will not be processed
and you will continue to receive a check.
I hereby acknowledge that my revenue detail will only be available electronically via www.energylink.com.
.
Return the form, along with a voided check (no deposit slip accepted), via mail to HighMark Energy Operating, LLC, Attn:
Accounting, 909 Lake Carolyn Pkwy, Suite 1500, Irving, TX 75039 or fax to 972-556-2953, attention to Accounting / Direct Deposit.
If you need additional information related to Direct Deposit (ETF) payments, please call 972-556-2950 or email us at
[email protected] .