Xpressfund (ACH) Authorization

User Name or Account # _________________________________

First Name ____________________________________________ Last Name _____________________________________________

Date of Birth _________ / _________ / ____________________

Address _____________________________________________________________________________________________________

City _____________________________________________________________ State ______________ Zip_____________________

Please make this my Xpressfund account of record for my future use

Checking Savings

Bank Name: _______________________________________________________

Transit/ABA Number: ________________________________________________

Account Number: ___________________________________________________

This form is required for identification purposes and for the security of your transaction. You may mail or fax the completed form to:

Xpressbet, LLC.
200 Racetrack Road, Building 26
Washington, PA 15301

Fax: 866.997.7737

I hereby authorize Xpressbet, LLC. to initiate a debit, in the amount indicated, to my checking/savings account in the depository financial institution (Bank) identified by the routing number indicated, and bank to debit same to such account. I acknowledge that I have received services/goods in consideration hereof and I further agree that this authorization shall be non-revocable.

I agree to pay merchant a returned item fee of $25.00, which may be initiated to my account for the items returned unpaid. And, in the event of returned items, I authorize Xpressbet to collect returned funds from other forms of payment I have previously used to make deposits.

Please attached a voided check.

Signature _____________________________________________________________________ Date __________________________