AutoPay ACH Authorization Agreement

I hereby authorize DDBC Inc., dba eHealthApp to initiate debit entries to the financial institution account indicated below. This debit
is to satisfy the outstanding balance for eHealthApp services and related fees, each month as outlined in the Service Agreement.
I understand that changes such as bank account number change, will require a new ACH Authorization Form to be filled out and
submitted. If my transaction is rejected for any reason (insufficient funds, closed account, bank error, etc.), other than a DDBC Inc.,
dba eHealthApp error, my account will be charged a fee of $25.00 (or the amount allowable by law), which may be automatically
debited for each occurrence.
This authorization shall remain in effect until eHealthApp receives written notification to terminate. This must be made in a timely
manner to allow DDBC Inc., dba eHealthApp a reasonable opportunity to act on such notice (30 days).

DATE:

New Authorization

Change Existing Authorization

Delete Authorization

eHealthApp ACCOUNT INFORMATION

eHealthApp Account Name:
eHealthApp url Broker ID:
example: http://Acme.eHealthApp.com
FUNDS SETTLEMENT INFORMATION

Checking Account
Savings Account

Bank Name:
Bank Street Address:

City:

State:

Zip:

Bank Account Owner:

Bank Account Name:
as it appears on a check or Statement
Routing Number:
9 digits

Bank Account Number:

SIGNATURES

I represent and warrant that I am authorized to execute this authorization. I indemnify and hold DDBC Inc., dba eHealthApp
harmless from damage, loss or claim resulting from all authorized actions hereunder.
Bank Accountholder Signature:

Bank Accountholder Printed Name

2nd Bank Accountholder Signature (if required):

2nd Bank Accountholder Printed Name

NEXT STEPS

Send completed form via email (billing@ehealthapp.com), fax 877-255-3322, or mail 7154 W State St #407 Boise, ID 83714.
Completed authorization forms must reach our office by the 15th of the current month to begin automatic deductions which occur
between the 2nd and 7th of each month. Example: ACH authorization agreement is received on May 14th. On or around June 3rd,
the payment due amount from the invoice that was sent on May 1st will be deducted.

Charges will appear on your bank statement from eHealthApp Colle

A voided check or a bank letter must accompany this authorization form.

Sample Routing #
billing@ehealthapp.com

Sample Account #
Office: 877.342.8462