COMMUNITY INTERNET SYSTEMS, INC.
AUTOMATIC PAYMENT PLAN AGREEMENT

AUTHORIZATION FOR DIRECT DEPOSITS/PAYMENTS (ACH DEBITS/CREDITS)
Company/ Individual Name  ____________________________________ 

Address ____________________________________________________
                                   City________________________________________________________
                                   State_______________________________________________________

Postal Code__________________________________________________
                                
Phone Number (____) ___-_____
 
I (we) hereby authorize the Community Internet Systems, Inc., hereinafter called CIS, to initiate debit/credit entries to my (our) Checking Account indicated on the attached voided check at the depository financial institution named on such document, hereinafter called DEPOSITORY, and to debit/credit the same to such account. I (we) acknowledge that the origination of CIS transactions to my (our) account must comply with the provisions of U.S. law.

This authorization is to remain in full force and effect until CIS has received written notification (signed by all names on bank account) of its termination in such time and in such manner as to afford CIS and DEPOSITORY a reasonable opportunity to act on it.

List of CIS Username (s)
 

____________________ ____________________ ____________________
____________________ ____________________ ____________________
____________________ ____________________ ____________________

OR  Check here for all accounts for this customer
(Please attach list of accounts if more space is needed.)

ATTACH VOIDED CHECK
(all names on bank account need to sign below )

Print Name _________________ Signature _________________ Date _______

Print Name _________________ Signature _________________ Date _______

NOTE: ALL WRITTEN DEBIT/CREDIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.