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Submit Direct Deposit Information First Name I hereby authorize my employer, (hereinafter COMPANY), to deposit any amounts owed me by initiating credit entries to my account at the financial institution(s) (hereinafter BANK) indicated below. Further, I authorize BANK to accept and to credit any credit entries indicated by COMPANY to my account. In the event that COMPANY deposits funds erroneously into my account, I authorize COMPANY to debit my account for an amount not to exceed the original amount of the erroneous credit. Last Name Social Security # Employer   Account 1 Bank Name Branch Name City State Zip Code Account Number ABA / Transit / Routing # Account Type Checking Savings Amount   Account 2 Bank Name Branch Name City State Zip Code Account Number ABA / Transit / Routing # Account Type Checking Savings Amount For my convenience, I request that Alpine Benefits, Inc. (hereinafter Alpine) directly, deposit my wages/salary earned from my employer, into my bank account. I understand that deposit of my earnings into my account by Alpine may be an advance of funds on behalf of my employer, which is subject to the successful collection of these funds by Alpine from my employer's bank. If, within 30 days of Alpine making the deposit into my account, my employer does not make available to Alpine the funds that were advanced to make the deposit into my account, I authorize Alpine to charge my account to recover said advance. I agree to hold Alpine harmless from loss and to indemnify it, limited to the amount of the deposit. Any dispute arising out of or in connection with this agreement, if not otherwise resolved, shall be determined by arbitration in Provo, Utah, in accordance with the Rules of the American Arbitration Association, and it is the expressed desire of both parties that the prevailing party be awarded costs and attorney's fees and that the award be entered as a judgment in any jurisdiction in which the non-prevailing party does business. This authorization is to remain in full force and effect until COMPANY and BANK have received written notice from me of its termination in such time and in such manner as to afford COMPANY and BANK a reasonable opportunity to act on it. By submitting this form the employee agrees to the above terms.

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