STATE OF ALASKA

1 ZIP CODE + 4 ARE YOU ADDING,CHANGING (must provide PRIOR acct info)OR CANCELLING THIS AGREEMENT? *FINANCIAL INSTITUTION NAMEACCOUNT NAME (Business / Legal Name on Account)CheckingSavingsIS THIS ACCOUNT PRIMARILY A PERSONAL OR BUSINESS ACCOUNT? *PERSONAL- OR -BUSINESSFOR BUSINESS ACCOUNTS. Choose ONE of the business account addenda information format options *Indicates required ADDRESS for copies of remit advicePayments deposited separately with one addendum (remittance) record for each combined into one deposit with multiple addenda (remittance) records for each payment in the StateofAlaska sends a pre-note zero dollar test transactiontoverify the accuracyofthe banking information below.

2 Paymentswillnotbesent electronically until the pre-note processis complete, generally five business days. The StateofAlaskawillcontact youif thepre-note TRANSIT NUMBERFULL ACCOUNT NUMBERFULL ACCOUNT NUMBERSTATE OF ALASKAFOR VENDORS DOING BUSINESS WITH THE STATE OF ALASKAMail completed form to:DEPT OF ADMINISTRATION / DIV OF FINANCEPO BOX 110204 / JUNEAU AK 99811-0204or FAX to: (907) 465-2169 Questions? Call (907) 465-5622 ELECTRONIC PAYMENT AGREEMENTTYPEACCOUNTABA/ROUTING TRANSIT NUMSTATE OF ALASKA VENDOR NUMBERTAXPAYER ID - SSN / EIN *ID number assigned to the legal name below and used for tax reportingNEW? * YES / NOSIGNATURE *DATE *NACHA Operating Rules requires your banking institution to provide you with addenda (remittance) information that the STATE includes on each payment.

3 Any banking charge to receive this information is the responsibility of the account AND AUTHORIZATIONI hereby authorize the StateofAlaskatosatisfy payment obligationsduemebymaking depositstothe account indicated above. I understand that receiptoftheelectronic fund transfer(s) will fulfill theState spayment obligation and the STATE willbecredited for the full amountonthe date the fund transferiscompleted. Iunderstand the STATE will make a reasonable efforttonotifymewithin24hoursif a reversing entryismade against this account. This authorityis toremaininfull forcethrough the duration of this agreement. I understand that thirty (30) days written notice is required if I change financial institutions, account numbers or type of account.

4 Inaddition,asrequiredbythe Federal OfficeofForeign Asset Title50,War and National Defense, I attest that the full amountofmydirectdepositis not being forwardedtoa bankinanother country and thatif atany point I establish a standing order withmyreceiving banktoforward the full direct deposittoa bank in another country, I will inform the STATE of ALASKA certify all information regarding this authorization is true and correct. Any intent to falsify information is punishable under AS as a class A misdemeanor. If the STATE discovers that the full amountofa direct deposit has been forwardedtoanother countryorif informationonthe form has been falsified, this agreement shallbeterminated.

5 All correspondence with the STATE concerning this agreementorany changestoaccount information shouldbesenttothe addressatthe topofthis terms remain in effect until this agreement is terminated by either NAME *TITLEP lease attach a voided check or other bank verification of account number as applicableBANKING INFORMATIONCURRENT ACCOUNT INFORMATION *For verification purposes you must provide your prior account information if you are requesting a ACCOUNT INFORMATION (for Changes only)PAYEE INFORMATIONLEGAL NAME * (Name that Tax ID above is assigned to and is used for tax reporting)CONTACT NAMEDAYTIME PHONE *CONTACT EMAIL ADDRESS IS MAILING ADDRESSMAILING ADDRESS *CITY BUSINESS NAME (DBA - Doing Business As Name.)

6 If different from legal name shown above)For EFT Payment Inquiry and other electronic payment information, visit our website at: 01/27/2016