Gibson Sanitation, Llc

GIBSON SANITATION, LLC

P.O. BOX 117

CANNON FALLS, MN 55009

507-263-4330

I (we) authorize GIBSON SANITATION, LLC & First Farmers & Merchants Bank to electronically debit my (our) account (and, if necessary, electronically credit my (our) account to correct erroneous debits) as follows:

o Checking Account

o Savings Account

Bank Name______________________________________________

Routing Number__________________________________________

Account Number__________________________________________

Amount of debit(s) range: $______________ to $_______________.

Frequency of debit: __________________ (ie: monthly, bi-monthly, annually)

I (we) understand that this authorization will remain in full force and effect until I (we) notify GIBSON SANITATION, LLC in the manner (writing, phone) that I (we) wish to revoke this authorization. I (we) understand that GIBSON SANITATION, LLC requires at least 30 days prior notice in order to cancel this authorization.

NAME GIBSON ACCOUNT #

SIGNATURE DATE PHONE #

**PLEASE INCLUDE VOIDED CHECK FOR VERIFICATION