AUTHORIZATION STATEMENT

(Name of your bank) X____________________________ is instructed to mail National Check Retrieval LLC all checks that have been given to us by our customers that have been unpaid by their bank.  These checks are not to be held or redeposited. They are to be sent immediately when first dishonored to:

National Check Retrieval LLC

12123 Shelbyville Road

Suite 100-173

Louisville, KY   40243

This authorization supersedes and cancels all prior authorizations and instructions for check  forwarding. This authorization remains in effect from this date forward until the above named bank has received written notice.

Name of Bank:  X_____________________________________________________

 Address:  X_________________________________________________________

City:  X_____________________________________St. X_______Zip:X_________

Phone: X_______________________________Fax: X________________________

Bank Customer X: ____________________________________________________

Address: X _________________________________________________________

City:  X_________________________________State:X________ Zip X_________

Routing Number: ___________________________

Signature: SIGN HERE X________________________________Date:X__________

Printed Name:X _____________________________Title: X___________________

Phone: X_____________________  Fax: X ______________________

Important: If you should have any questions regarding this authorization, please contact our Customer Service Department at:  Phone:  877-363-0786  Fax: 502-244-8964

Please staple voided check here – This is the account recovered checks will be electronically deposited to: