Common use of Privacy Act Notice Clause in Contracts

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency Direct Deposit Authorization Form Use this form to enroll in direct deposit. Please complete the form and submit to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Broker/Agency Information Broker/Agency Name: Tax ID Number: I authorize CoPower to initiate electronic credit entries each commission pay period and, if necessary, debit entries and adjustments for any credit entries in error to my account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it in writing. Broker/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: Date: / / Name: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx Xxxx. Suite 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • E-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxx

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished. Circle the minor’s name and furnish the minor’s SSN. DEPARTMENT OF HUMAN SERVICES Child Care Assistance Program 0000 Xxxx Xxxxxx Xxxxx Xxxx Xxxxxxx, CO 80524 (000) 000-0000 Fax: (000) 000-0000 Dear Child Care Provider, You have a choice of how you will receive your child care payment. Below are the choices you have and a little information about each choice. Direct Deposit Authorization  Your payment will go directly into your checking or savings account. The first month may need to be on a Colorado Quest Card. The following month, your payment will go to your bank account. With Direct Deposit your payment should be available to you the Wednesday or Thursday after our payroll closes. Colorado EBT – Quest Card  The Quest Card is issued to you and your childcare payments are put on the card. The card is somewhat like a debit card. You can access your money at grocery stores, other retailers and ATM’s (remember ATM’s do charge a fee, which would reduce your amount). You will have access to your money on the Monday after our payroll closes. This is the fastest way to get your payment. You will need to come into our Fort Xxxxxxx office to get your card and to select your Personal Identification Number (PIN). If you already have an EBT Quest Card, your childcare payments can be added to your existing card. PLEASE SELECT ONLY ONE OF THE FOLLOWING CHOICES: I currently receive direct deposit and would like to continue. Direct Deposit into Checking or Savings account (please fill out the form “ACH FORM FOR COLORADO PROVIDERS, For Direct Deposit Payments” & return it with your packet. Check here if you already have an EBT Card and would like your childcare payments added on to your card. New Colorado EBT Quest Card (Contact Xxxx Xxxxxx at 000-0000) Pick up your Colorado EBT Quest Card at: Larimer County Department of Human Services 0000 Xxxx Xxxxxx Xxxxx Fort Xxxxxxx, CO 80524 * Bring a picture I.D. Provider Signature Date Social Security Number or Provider ID# LCHS 4220 (07/10) Provider Direct Deposit Enrollment Form Use For Colorado Cash Assistance Benefits ***PROVIDER NUMBER REQUIRED FOR ENTRY*** (if you are unsure of your provider number please reach out to your local county office) Child Care (CC) Xxxxxx/Adoptive (CW) (5+ digits) CBMS CW/TANF & AF-Burial (9 digit EFT Number) LEAP (LE) CORE, CASE (CW3) (5+ digits) CBMS Nursing Home (NH) (5+ digits) Name of person completing this section: Phone (include area code) ( ) - I am completing this form to: (please check one option only) ☐✔ Enroll in ACH Direct Deposit into my personal bank account ☐✔ Change my Direct Deposit banking information or ☐ Cancel Direct Deposit I (we) hereby authorize Colorado Department of Human Services (CDHS), to enroll initiate credit entries, and if necessary, reverse any incorrect EFT credit entries made in error to the bank account indicated below, in accordance with standard banking procedures, for payments related to the Colorado Electronic Benefit Transfer (EBT) Programs. Provider Name (or Business Name) Address City _ State Zip Phone Number (including area code) ( ) - Federal E.I.N. Number _ - OR Social Security Number _ ☐ Bank Account Information (please check one option only): Checking Account or ☐Savings Account Bank Account Number Bank Name City State Zip Bank Routing Number (9-digit) (Check with your bank to ensure that this number is correct for direct deposit) This agreement is to remain in effect until CDHS, has received written notification of its termination in such time and manner to afford CDHS a reasonable opportunity to act on it. It is the responsibility of the vendor/provider to fill out and submit a new Authorization Agreement to CDHS if the vendor/provider changes or closes the account. Provider/Vendor Signature Date Please return the completed form and voided check or bank letter to the State EBT Program using one of the methods below to begin receiving payments by direct deposit. Please complete keep a copy of this form for your records.  Email: xxxx_xxx_xxxxxx@xxxxx.xx.xx (preferred method)  Fax: (000)000-0000  Mail: CDHS/EBT Program, 0000 Xxxxxxx Xx., 3rd Floor, Denver, Colorado 80203 Rev 08.23.2017 Formulario de inscripción de depósito directo del proveedor para beneficios de ayuda en efectivo de Colorado ***SE REQUIERE EL NÚMERO DE PROVEEDOR *** (si no está seguro del número de su proveedor comuníquese con la oficina local de su condado) Cuidado infantil (CC) Tutelar/adoptivo (CW) (5+ dígitos) CBMS CW/TANF y AF-Burial (entierro) (Número EFT de 9 dígitos) LEAP (LE) CORE, CASE (CW3) (5+ dígitos) Residencia de ancianos de CBMS (NH) (5+ dígitos) Nombre de la persona que llena esta sección: Teléfono (incluir el código de área) ( ) - Lleno este formulario para: (marque solo una opción) ☐ Inscribir el depósito directo ACH en mi cuenta bancaria personal ☐ Cambiar mi información bancaria de depósito directo o ☐ Cancelar el depósito directo Autorizo/autorizamos por este medio al Departamento de Servicios Humanos de Colorado (CDHS) a dar crédito, y si fuera necesario, reversar cualquier crédito incorrecto, mediante transferencia electrónica de fondos, (Electronic Funds Transfer, EFT) a la cuenta bancaria que se indica más abajo, de conformidad con los procedimientos bancarios convencionales, para pagos relacionados con los programas de transferencia electrónica de beneficios (Electronic Benefit Transfer, EBT) de Colorado. Nombre del proveedor (o nombre comercial) Dirección Ciudad Estado Código postal Número de teléfono (incluir el código de área) ( ) - E.I.N. (N.º de ident. el empleador) federal - O Número del seguro social ☐✔ Información de la cuenta bancaria (marque solo una opción): Cuenta bancaria o ☐Cuenta de ahorros Número de cuenta bancaria Nombre del banco Ciudad Estado Código postal Número de ruta y tránsito (9-dígitos) (Consulte a su banco para asegurarse de que este número sea correcto para depósito directo) Este acuerdo seguirá vigente hasta que CDHS haya recibido la notificación por escrito de su terminación en tiempo y manera que dé a CDHS una posibilidad razonable de obrar en consecuencia. El proveedor/la empresa proveedora será responsable de llenar y presentar un nuevo acuerdo de autorización a CDHS si el proveedor/la empresa proveedora cambia o cierra la cuenta. Firma del proveedor/empresa proveedora Fecha Devuelva el formulario completado y un cheque anulado o una carta del banco al programa de EBT estatal mediante uno de los métodos que se indican a continuación para comenzar a recibir pagos por depósito directo. Guarde una copia de este formulario xxxx xxxxxxxxxx.  Correo electrónico: xxxx_xxx_xxxxxx@xxxxx.xx.xx (método preferente)  Fax: (000)000-0000  Correo postal: CDHS/EBT Program, 0000 Xxxxxxx Xx., 3rd Floor, Denver, Colorado 80203 Rev 08.23.2017 Provider Information Bulletin To: CCAP Providers From: CHATS Implementation Team Date: July 1, 2010 Re: Provider Training and Registration Child Care Assistance Program Mandatory Provider Training and Class Registration Information The new Childcare Assistance Tracking System or CHATS has been implemented in five pilot counties in the form State which include; El Paso, Lincoln, Larimer, Summit and submit Weld counties. This is the system that is used to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Broker/Agency Information Broker/Agency Name: Tax ID Number: I authorize CoPower track attendance that generates payment to initiate electronic credit entries each commission pay period andchild care providers that accommodate the State’s Child Care Assistance Program, if necessary, debit entries and adjustments for any credit entries in error to my accountCCAP. I acknowledge It was also introduced that the origination State is requiring all providers to attend a Provider Training Workshop. Licensed Child Care Centers, Licensed Family Child Care Homes, and Qualified Family Child Care Homes You should already be working with your County on a new Fiscal Agreement and Point-of-Service (POS) Agreement in order to remain a CCAP Provider. ***THIS IS A REQUIREMENT IN ORDER TO BE CONTRACTED WITH LARIMER COUNTY*** To register for the classes below, please contact the registration person listed below. Providers may attend any of ACH transactions to my account must comply with the provisions trainings offered. If you have any questions about training, Fiscal or POS Agreements or general questions about the new system, please email XXXXX.XxxxxxxxxxxXxxxxxx@xxxxx.xx.xx Thank you, Larimer County CCAP Date & Time Location Call for Registration First Wednesday of U.S. laweach month. This authority will remain in effect until I have cancelled it in writing. Broker/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: Date: / / Name: Title: Attach Voided Check CoPower • 1:30 p.m. Room 124 0000 X. Xxxxxxxxx Xxxx. Suite 000, Xxx Xxxxxxxx Xxxxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • EXxxxx 000 Xxxx Xxxxxxx, CO 80525 Gail (000) 000-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxx0000 or Xxxxx (000) 000-0000

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency Authorization For Direct Deposit Authorization Form Use this of Payment (please complete form to enroll in direct deposit. Please complete the form and submit to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Brokerits entirety) Select Company Reset BUSINESS INFORMATION Agency/Agency Information Broker/Agency Agent Name: Tax ID Number/SSN last four digits (whichever applies) Receive e-mail statement? YES NO Phone Number: TO RECEIVE E-MAILED STATEMENTS, via secure e-mail, (E-mail can only be sent to ONE address) ENTER E-MAIL ADDRESS BELOW: BANK OR FINANCIAL INSTITUTION INFORMATION PLEASE ATTACH A DEPOSIT SLIP OR "VOIDED CHECK" Select One: New Account Financial Institution Name (as it appears on savings/checking account) Account Change Cancel Deposit Routing Number (9 digits): Type of Account: Savings Account No. Checking Account No. AUTHORIZATION STATEMENT By signing below, I request and authorize CoPower the Company stated above to initiate electronic credit entries deposit automatically to the checking or savings account stated in this authorization. I agree that each commission pay period anddeposit the Company makes to this account will be a payment to me, if necessary, debit entries and adjustments for any credit entries in error without regard to my the person or persons that may withdraw or receive funds from that account. I acknowledge that the origination of ACH transactions Adjusting entries to my account must comply with the provisions of U.S. lawcorrect errors are also authorized. This authority will remain in effect until I have cancelled canceled it in writing. Broker/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: DateDate : / / NamePlease return this Authorization for Direct Deposit of Payment along with a Deposit Slip or "VOIDED" check to the following e-mail address or fax number: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx Xxxx. Suite 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • xxxxxxxxxxx@xxxxxxxxxxxxx.xxx Fax: 000.000.0000 • E(000) 000-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxx0000 RETAIN A COPY OF THIS COMPLETED AGREEMENT FOR YOUR RECORDS 11/01/2017

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRAXXX, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency Direct Deposit Authorization Reset Form Use Print and Reset Form YEAR 20☐☐ Withholding Exemption Certificate File this form with your withholding agent.(Please type or print) Withholding agent’s name Vendor/Payee’s name Vendor/Payee’s ☐ Social security number ☐ SOS no. ☐ California corp. no. ☐ FEIN Note: Failure to enroll in direct depositfurnish your identification number will make this certificate void. Please complete the Vendor/Payee’s address (number and street) APT no. Private Mailbox no. Vendor/Payee’s daytime telephone no. ( ) (This form and submit can only be used to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Broker/Agency Information Broker/Agency Name: Tax ID Number: I authorize CoPower to initiate electronic credit entries each commission pay period and, if necessary, debit entries and adjustments for any credit entries in error to my account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. lawcertify exemption from nonresident withholding under California R&TC Section 18662. This authority will remain in effect until form cannot be used for exemption from wage withholding.) CALIFORNIA FORM City State ZIP Code I have cancelled it in writingcertify that for the reasons checked below, the entity or individual named on this form is exempt from the California income tax withholding requirement on payment(s) made to the entity or individual. BrokerRead the following carefully and check the box that applies to the vendor/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: Date: / / Name: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx Xxxx. Suite 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • E-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxxpayee:

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency Authorization For Direct Deposit Authorization Form Use this of Payment (please complete form to enroll in direct deposit. Please complete the form and submit to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Brokerits entirety) Select Company Reset BUSINESS INFORMATION Agency/Agency Information Broker/Agency Agent Name: Tax ID Number/SSN last four digits (whichever applies) Receive e-mail statement? YES NO Phone Number: TO RECEIVE E-MAILED STATEMENTS, via secure e-mail, (E-mail can only be sent to ONE address) ENTER E-MAIL ADDRESS BELOW: BANK OR FINANCIAL INSTITUTION INFORMATION PLEASE ATTACH A DEPOSIT SLIP OR "VOIDED CHECK" Select One: New Account Financial Institution Name (as it appears on savings/checking account) Account Change Cancel Deposit Routing Number (9 digits): Type of Account: Savings Account No. Checking Account No. AUTHORIZATION STATEMENT By signing below, I request and authorize CoPower the Company stated above to initiate electronic credit entries deposit automatically to the checking or savings account stated in this authorization. I agree that each commission pay period anddeposit the Company makes to this account will be a payment to me, if necessary, debit entries and adjustments for any credit entries in error without regard to my the person or persons that may withdraw or receive funds from that account. I acknowledge that the origination of ACH transactions Adjusting entries to my account must comply with the provisions of U.S. lawcorrect errors are also authorized. This authority will remain in effect until I have cancelled canceled it in writing. Broker/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: DateDate : / / NamePlease return this Authorization for Direct Deposit of Payment along with a Deposit Slip or "VOIDED" check to the following e-mail address or fax number: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx Xxxx. Suite 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • xxxxxxxxxxx@xxxxxxxxxxxxx.xxx Fax: 000.000.0000 • E(000) 000-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxx0000 RETAIN A COPY OF THIS COMPLETED AGREEMENT FOR YOUR RECORDS

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished. Circle the minor’s name and furnish the minor’s SSN. DEPARTMENT OF HUMAN SERVICES Child Care Assistance Program 0000 Xxxx Xxxxxx Xxxxx Xxxx Xxxxxxx, CO 80524 (000) 000-0000 Fax: (000) 000-0000 Dear Child Care Provider, You have a choice of how you will receive your child care payment. Below are the choices you have and a little information about each choice. Direct Deposit Authorization  Your payment will go directly into your checking or savings account. The first month may need to be on a Colorado Quest Card. The following month, your payment will go to your bank account. With Direct Deposit your payment should be available to you the Wednesday or Thursday after our payroll closes. Colorado EBT – Quest Card  The Quest Card is issued to you and your childcare payments are put on the card. The card is somewhat like a debit card. You can access your money at grocery stores, other retailers and ATM’s (remember ATM’s do charge a fee, which would reduce your amount). You will have access to your money on the Monday after our payroll closes. This is the fastest way to get your payment. You will need to come into our Fort Xxxxxxx office to get your card and to select your Personal Identification Number (PIN). If you already have an EBT Quest Card, your childcare payments can be added to your existing card. PLEASE SELECT ONLY ONE OF THE FOLLOWING CHOICES: I currently receive direct deposit and would like to continue. Direct Deposit into Checking or Savings account (please fill out the form “ACH FORM FOR COLORADO PROVIDERS, For Direct Deposit Payments” & return it with your packet. Check here if you already have an EBT Card and would like your childcare payments added on to your card. New Colorado EBT Quest Card (Contact Xxxx Xxxxxx at 000-0000) Pick up your Colorado EBT Quest Card at: Larimer County Department of Human Services 0000 Xxxx Xxxxxx Xxxxx Fort Xxxxxxx, CO 80524 * Bring a picture I.D. Provider Signature Date Social Security Number or Provider ID# LCHS 4220 (07/10) Provider Direct Deposit Enrollment Form Use For Colorado Cash Assistance Benefits ***PROVIDER NUMBER REQUIRED FOR ENTRY*** (if you are unsure of your provider number please reach out to your local county office) Child Care (CC) Xxxxxx/Adoptive (CW) (5+ digits) CBMS CW/TANF & AF-Burial (9 digit EFT Number) LEAP (LE) CORE, CASE (CW3) (5+ digits) CBMS Nursing Home (NH) (5+ digits) Name of person completing this section: Phone (include area code) ( ) - I am completing this form to: (please check one option only) ☐✔ Enroll in ACH Direct Deposit into my personal bank account ☐✔ Change my Direct Deposit banking information or ☐ Cancel Direct Deposit I (we) hereby authorize Colorado Department of Human Services (CDHS), to enroll initiate credit entries, and if necessary, reverse any incorrect EFT credit entries made in error to the bank account indicated below, in accordance with standard banking procedures, for payments related to the Colorado Electronic Benefit Transfer (EBT) Programs. Provider Name (or Business Name) Address City _ State Zip Phone Number (including area code) ( ) - Federal E.I.N. Number _ - OR Social Security Number _ ☐ Bank Account Information (please check one option only): Checking Account or ☐Savings Account Bank Account Number Bank Name City State Zip Bank Routing Number (9-digit) (Check with your bank to ensure that this number is correct for direct deposit) This agreement is to remain in effect until CDHS, has received written notification of its termination in such time and manner to afford CDHS a reasonable opportunity to act on it. It is the responsibility of the vendor/provider to fill out and submit a new Authorization Agreement to CDHS if the vendor/provider changes or closes the account. Provider/Vendor Signature Date Please return the completed form and voided check or bank letter to the State EBT Program using one of the methods below to begin receiving payments by direct deposit. Please complete the keep a copy of this form and submit to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Broker/Agency Information Broker/Agency Namefor your records.  Email: Tax ID Number: I authorize CoPower to initiate electronic credit entries each commission pay period and, if necessary, debit entries and adjustments for any credit entries in error to my account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it in writing. Broker/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: Date: / / Name: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx Xxxx. Suite 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • xxxx_xxx_xxxxxx@xxxxx.xx.xx (preferred method)  Fax: 000.000.0000 • E(000)000-mail0000  Mail: xxxxxxx.xxxxxxxx@xxxxxx.xxxCDHS/EBT Program, 0000 Xxxxxxx Xx., 3rd Floor, Denver, Colorado 80203 Rev 08.23.2017 Formulario de inscripción de depósito directo del proveedor para beneficios de ayuda en efectivo de Colorado ***SE REQUIERE EL NÚMERO DE PROVEEDOR *** (si no está seguro del número de su proveedor comuníquese con la oficina local de su condado) Cuidado infantil (CC) Tutelar/adoptivo (CW) (5+ dígitos) CBMS CW/TANF y AF-Burial (entierro) (Número EFT de 9 dígitos) LEAP (LE) CORE, CASE (CW3) (5+ dígitos) Residencia de ancianos de CBMS (NH) (5+ dígitos) Nombre de la persona que llena esta sección: Teléfono (incluir el código de área) ( ) - Lleno este formulario para: (marque solo una opción) ☐ Inscribir el depósito directo ACH en mi cuenta bancaria personal ☐ Cambiar mi información bancaria de depósito directo o ☐ Cancelar el depósito directo Autorizo/autorizamos por este medio al Departamento de Servicios Humanos de Colorado (CDHS) a dar crédito, y si fuera necesario, reversar cualquier crédito incorrecto, mediante transferencia electrónica de fondos, (Electronic Funds Transfer, EFT) a la cuenta bancaria que se indica más abajo, de conformidad con los procedimientos bancarios convencionales, para pagos relacionados con los programas de transferencia electrónica de beneficios (Electronic Benefit Transfer, EBT) de Colorado. Nombre del proveedor (o nombre comercial) Dirección Ciudad Estado Código postal Número de teléfono (incluir el código de área) ( ) - E.I.N. (N.º de ident. el empleador) federal - O Número del seguro social ☐✔ Información de la cuenta bancaria (marque solo una opción): Cuenta bancaria o ☐Cuenta de ahorros Número de cuenta bancaria Nombre del banco Ciudad Estado Código postal Número de ruta y tránsito (9-dígitos) (Consulte a su banco para asegurarse de que este número sea correcto para depósito directo) Este acuerdo seguirá vigente hasta que CDHS haya recibido la notificación por escrito de su terminación en tiempo y manera que dé a CDHS una posibilidad razonable de obrar en consecuencia. El proveedor/la empresa proveedora será responsable de llenar y presentar un nuevo acuerdo de autorización a CDHS si el proveedor/la empresa proveedora cambia o cierra la cuenta. Firma del proveedor/empresa proveedora Fecha Devuelva el formulario completado y un cheque anulado o una carta del banco al programa de EBT estatal mediante uno de los métodos que se indican a continuación para comenzar a recibir pagos por depósito directo. Guarde una copia de este formulario xxxx xxxxxxxxxx.  Correo electrónico: xxxx_xxx_xxxxxx@xxxxx.xx.xx (método preferente)  Fax: (000)000-0000  Correo postal: CDHS/EBT Program, 0000 Xxxxxxx Xx., 3rd Floor, Denver, Colorado 80203

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished. Circle the minor’s name and furnish the minor’s SSN. DEPARTMENT OF HUMAN SERVICES Child Care Assistance Program 0000 Xxxx Xxxxxx Xxxxx Xxxx Xxxxxxx, CO 80524 (000) 000-0000 Fax: (000) 000-0000 Dear Child Care Provider, You have a choice of how you will receive your child care payment. Below are the choices you have and a little information about each choice. Direct Deposit  Your payment will go directly into your checking or savings account. The first month may need to be on a Colorado Quest Card. The following month, your payment will go to your bank account. With Direct Deposit your payment should be available to you the Wednesday or Thursday after our payroll closes. Colorado EBT – Quest Card  The Quest Card is issued to you and your childcare payments are put on the card. The card is somewhat like a debit card. You can access your money at grocery stores, other retailers and ATM’s (remember ATM’s do charge a fee, which would reduce your amount). You will have access to your money on the Monday after our payroll closes. This is the fastest way to get your payment. You will need to come into our Fort Xxxxxxx office to get your card and to select your Personal Identification Number (PIN). If you already have an EBT Quest Card, your childcare payments can be added to your existing card. PLEASE SELECT ONLY ONE OF THE FOLLOWING CHOICES: I currently receive direct deposit and would like to continue. Direct Deposit into Checking or Savings account (please fill out the form “ACH FORM FOR COLORADO PROVIDERS, For Direct Deposit Payments” & return it with your packet. Check here if you already have an EBT Card and would like your childcare payments added on to your card. New Colorado EBT Quest Card (Contact Xxxx Xxxxxx at 000-0000) Pick up your Colorado EBT Quest Card at: Larimer County Department of Human Services 0000 Xxxx Xxxxxx Xxxxx Fort Xxxxxxx, CO 80524 * Bring a picture I.D. Provider Signature Date Social Security Number or Provider ID# LCHS 4220 (07/10) ACH FORM FOR COLORADO PROVIDERS FOR DIRECT DEPOSIT PAYMENTS TO PROVIDERS I (we) hereby authorize X.X. Xxxxxx Electronic Financial Services, Inc. (JPMorgan EFS), as designated agent for the Colorado Department of Human Services (CDHS), to initiate credit entries, and if necessary, reverse any incorrect EFT credit entries made in error to the bank account indicated below, in accordance with standard banking procedures, for payments related to the Colorado Electronic Benefits Transfer (EBT) Program. County Use Only: PROVIDER NUMBER REQUIRED FOR ENTRY Child Care (CC) Xxxxxx/Adoptive (CW) Colo. Works, TANF, COIN (9 digit) LEAP (LE) Nursing Home (NH) CORE, CASE (CW3) Name of county staff member completing this section: Phone # of county staff (include area code) ( ) - **All fields below must be completed in order to avoid delay in payment PROVIDER NAME ADDRESS CITY, STATE, ZIP TELEPHONE NUMBER (including area code) ( ) - FEDERAL E.I.N. NUMBER - OR SOCIAL SECURITY NUMBER - - CHECK HERE IF THIS IS A REQUEST TO CHANGE BANKING INFO PREVIOUSLY SUBMITTED: If a change of banking information, what is the effective date of this change: TYPE OF ACCOUNT (please check only one) Checking (attach voided check or letter from bank) Savings (attach voided deposit slip or letter from bank) ACCOUNT NUMBER NAME OF YOUR BANK TRANSIT/ROUTING NUMBER (Check with your bank to ensure that this nine-digit number is correct for direct deposit) This agreement is to remain in full force and effect until (JPMorgan EFS), as designated agent for CDHS, has received written notification from the vendor/provider of its termination in such time and manner to afford JPMorgan EFS a reasonable opportunity to act on it. It is the responsibility of the vendor/provider to fill out and submit a new Authorization Form Use this form Agreement to enroll in CDHS if the vendor/provider changes banks or accounts. Provider/Vendor Signature Date Please return the completed form, voided check or copy of a deposit slip to the State EBT Program using one of the methods below to begin receiving payments by direct deposit. Please complete the keep a copy of this form and submit for your records.  Email xxxx_xxx_xxxxxx@xxxxx.xx.xx, Fax (000)000-0000 or Mail to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 BrokerCDHS/Agency Information Broker/Agency NameEBT Program, 0000 Xxxxxxx Xx., 3rd Floor, Denver, Colorado 80203 _ For CDHS use only: Tax ID NumberReceived on: I authorize CoPower to initiate electronic credit entries each commission pay period and, if necessary, debit entries and adjustments for any credit entries in error to my account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it in writing. Broker/Agency Information Accountholder’s Name_ Entered on: Financial Institution_ Entered by: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: Date: / / Name: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx Xxxx. Suite 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • E-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxx_

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency Direct Deposit Authorization Form Use W-8ECI (Rev. July 2017) Department of the Treasury Internal Revenue Service Certificate of Foreign Person's Claim That Income Is Effectively Connected With the Conduct of a Trade or Business in the United States a Section references are to the Internal Revenue Code. a Go to xxx.xxx.xxx/XxxxX0XXX for instructions and the latest information. a Give this form to enroll in direct depositthe withholding agent or payer. Please complete Do not send to the IRS. OMB No. 1545-1621 Note: Persons submitting this form must file an annual U.S. income tax return to report income claimed to be effectively connected with a U.S. trade or business. See instructions. Do not use this form for: Instead, use Form: • A beneficial owner solely claiming foreign status or treaty benefits W-8BEN or W-8BEN-E • A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) W-8EXP Note: These entities should use Form W-8ECI if they received effectively connected income and submit are not eligible to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx claim an exemption for chapter 3 or via fax at 000.000.0000 Broker/Agency Information Broker/Agency Name: Tax ID Number: I authorize CoPower to initiate electronic credit entries each commission pay period and, if necessary, debit entries and adjustments for any credit entries in error to my account4 purposes on Form W-8EXP. I acknowledge that the origination of ACH transactions to my account must comply • A foreign partnership or a foreign trust (unless claiming an exemption from U.S. withholding on income effectively connected with the provisions conduct of U.S. lawa trade or business in the United States) W-8BEN-E or W-8IMY • A person acting as an intermediary W-8IMY Note: See instructions for additional exceptions. This authority will remain in effect until Part I have cancelled it in writing. Broker/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: Date: / / Name: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx Xxxx. Suite 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • E-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxxIdentification of Beneficial Owner (see instructions) 1 Name of individual or organization that is the beneficial owner 2 Country of incorporation or organization 3 Name of disregarded entity receiving the payments (if applicable)

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency Direct Deposit Authorization Form Use this form to enroll in direct deposit. Please complete the form and submit to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Broker/Agency Information Broker/Agency ACH AUTHORIZATION TYPE OF BANK ACCOUNT: ▭ Checking ▭ Savings BANKING INFORMATION: Financial Institution Name: Tax ID Number: I authorize CoPower to initiate electronic credit entries each commission pay period and, if necessary, debit entries and adjustments for any credit entries in error to my account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it in writing. Broker/Agency Information Accountholder’s Name: Account Number at Financial Institution: Routing/ABA Number: Account NumberFinancial Institution Routing Number for ACH: Financial Institution City, State, and Postal Code: State**PLEASE INCLUDE A COPY OF A VOIDED CHECK** Signature of Authorized Representative: Zip: Signature Signature: Date: / / Print Name: Title: Attach Voided Check CoPower GOLD STANDARD AUTOMOTIVE NETWORK P.O. Box 260 • Draper, UT 84020 000-000-0000 X. Xxxxxxxxx Xxxx. Suite or Toll-Free 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • E-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxx000-0000

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency Direct Deposit Authorization Form Use INSTRUCTIONS TO COMPLETE SFN 583 NORTH DAKOTA MEDICAID ELECTRONIC REMITTANCE ADVICE (835) ENROLLMENT If you choose to use Therap Services, LLC for billing, you are required to submit this form. If you are using another EVV System, you will need to contact them to determine if this form is required and for information needed to enroll complete this form. If you are submitting your own professional claims, this form is not required. This form must be submitted electronically, it will not be included in direct depositthis packet. Please Go to xxxxx://xxx.xx.xxx/eforms/Doc/sfn00583.pdf to locate this form. Provider Information • Provider Name – Enter your first and last name. • Street Address – Enter physical address. • Enter City. • Enter State. • Enter Zip Code. Provider Identifier Information • Provider Federal Tax Identification Number (TIN) – Enter your social security number. • National Provider Identifier (NPI) – Enter your NPI Number. • Trading Partner ID – If using Therap Services, LLC enter “ND QSP”. Provider Contact Information • Provider Contract Name – Enter your first and last name. • Telephone Number – Enter your telephone number. • Email Address – Enter your email address. Electronic Remittance Advise Information • Preference for Aggregation of Remittance Data o Choose “National Provider Identifier (NPI)” – Enter your NPI Number. • Method of Retrieval o Choose “Clearing House”. Electronic Remittance Advice Clearinghouse Information • Clearinghouse Name – Enter “Therap Services, LLC”. Submission Information • Reason for Submission o Choose “New Enrollment” Authorized Signature • Printed Name of Person Submitting Enrollment • Submission Date – Enter 4-digit year, month, day in this format: (CCYYMMDD). • Requested ERA Effective Date – Enter 4-digit year, month day in this format: (CCYYMMDD). Submit “By entering an “X” in the box, means I have read and agree to all the terms and conditions state above. If you have questions or to check the status of this ERA enrollment, please contact the North Dakota EDI Help Desk at: 0-000-000-0000 or xxxxxxxxx@xx.xxx. ATTN: EDI 835 Enrollment ND Department of Health and Human Services 000 X Xxxxxxxxx Xxx Bismarck, ND 58505-0250 After completing the form, save a copy and email as an attachment to xxxxxxxxx@xx.xxx. INSTRUCTIONS TO COMPLETE SFN 750 DOCUMENT OF COMPETENCY If you have one of the following current licenses or certifications, DO NOT COMPLETE this form. Your license or certification meets or exceeds the Department of Human Services competency standards. Registered Nurse Licensed Practical Nurse Registered Physical Therapist Registered Occupational Therapist Certified Nurse Assistant A copy of the current license/certificate or the license/certificate number must be sent with your enrollment forms. Certificates or other proof of completion of a training or education program focused on in­ home care will be considered, if proof is provided that standards 5 through 25 on SFN 750 are included in the curriculum, and the training program is provided by a licensed healthcare professional. The program must have a renewal process every two years. Refer to CHART B in your handbook for the global endorsements each health care professional will automatically be given. If you do not have one of the above, this form must be completed by a licensed healthcare provider to meet QSP requirements. You cannot fill out this form yourself. Physician Physician Assistant Chiropractor Nurse Practitioner Registered Nurse Licensed Practical Nurse Registered Occupational Therapist Registered Physical Therapist TO COMPLETE THE FORM: • Applicant/ Provider Name: Write the name of the person enrolling as a QSP • Standards 5 - 25: A health care professional must complete columns (3) and (4) to show the standards for which competency has been confirmed. CHART A in your handbook lists the requirements to meet each competency. • If enrolling for personal care services, you must show you know the generally accepted practices for ALL standards #5 through #25 even if you do not plan to provide one of the services listed. Failure to have all standards checked will result in denial of your application. • If enrolling only for the Homemaker service, you must show competency in standards # 5­11 on SFN 750 • Global Endorsements: Refer to the Family Personal Care (FPC) handbook for further information. 9 ■ The health care professional must complete columns (3) and (4) to show if competency is confirmed for each endorsement. ■ You will not be enrolled for the endorsement if the line is incomplete. • Professional Health Care Providers verification of competency • A Health Care Professional's signature and license number is required (instructions for the Health Care Professional are located on the back side of the SFN 750). • CHART B in your handbook shows which global endorsements certain health care professionals can authorize. If you are unable to find a health care professional to complete the form and submit SFN 750, contact Noridian for a referral to CoPower via ETrain ND. Noridian at 701­277­6933 (Voicemail only) or XXXXxxxxxxxxx@xxxxxxxx.xxx Clear Fields DOCUMENTATION OF COMPETENCY NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES MEDICAL SERVICES/HCBS SFN 750 (8-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx 2019) Provider Number (if known): Current QSP or via fax at 000.000.0000 Broker/Agency Information Broker/Agency Name: Tax ID Number: I authorize CoPower QSP Applicant Instructions to initiate electronic credit entries each commission pay period and, if necessary, debit entries and adjustments for any credit entries in error to my accountcomplete are listed on the back of this form. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. lawIncomplete forms will not be accepted. This authority will remain in effect until I have cancelled it in writing. Broker/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: Date: / / Name: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx Xxxx. Suite 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • E-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxxform must be completed by a health care professional (see reverse side for instructions).

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/FORM BMC-85 Revised 03/11/2014 OMB No.: 2126-0017 Expiration: 02/28/2017 A Federal Agency Direct Deposit Authorization Form Use this form may not conduct or sponsor, and a person is not required to enroll in direct deposit. Please complete the form and submit respond to, nor shall a person be subject to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Broker/Agency Information Broker/Agency Name: Tax ID Number: I authorize CoPower a penalty for failure to initiate electronic credit entries each commission pay period and, if necessary, debit entries and adjustments for any credit entries in error to my account. I acknowledge that the origination of ACH transactions to my account must comply with a collection of information subject to the provisions requirements of U.S. lawthe Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. This authority will remain in effect until I have cancelled it in writingThe OMB Control Number for this information collection is 2126-0017. Public reporting for this collection of information is estimated to be approximately 10 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions f or reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, Washington, D.C. 20590. United States Department of Transportation Federal Motor Carrier Safety Administration Broker/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: 's or Freight Forwarder's Trust Fund Agreement under 49 U.S.C. 13906 or Notice of Cancellation of the Agreement FORM BMC-85 License No. MC-221460 Filer FMCSA Account Number: Financial Institution City: State: Zip: Signature Signature: Date: / / Name: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx Xxxx. Suite 00022512 KNOW ALL MEN BY THESE PRESENTS, that we, Medallion Transport & Logistics LLC of 000 X Xxxx Xxxxx Xxx Xxxxx000 Xx Xxxxxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • E-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxxas TRUSTOR (hereinafter called Trustor), and Pacific Financial Association a financial institution created and existing under the laws of the State of California as TRUSTEE (hereinafter called Trustee), hold and firmly bind ourselves and our heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these presents.

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency Direct Deposit Authorization Form Use TAXABLE YEAR ‌ Nonresident Withholding CALIFORNIA FORM 2023 Allocation Worksheet 587 The payee completes this form and returns it to enroll the withholding agent. The withholding agent keeps this form with their records. Part I Withholding Agent Information Withholding agent’s name City of Sacramento Address (apt./ste., room, PO box, or PMB no.) City (If you have a foreign address, see instructions.) State ZIP code Part II Nonresident Payee Information Xxxxx’s name □ SSN or ITIN □ FEIN □ CA Corp no. □ CA SOS file no. Address (apt./ste., room, PO box, or PMB no.) City (If you have a foreign address, see instructions.) State ZIP code Nonresident payee’s entity type: (Check one) • Individual/sole proprietor • Corporation • Partnership • Limited liability company (LLC) • Estate or trust Part III Payment Type Nonresident payee: (Check one) □ Performs services totally outside California (no withholding required, skip to □ Provides goods and services in direct depositCalifornia (see Part IV, Income Allocation) Certification of Nonresident Payee) □ Provides services within and outside California (see Part IV, Income Allocation) □ Provides only goods or materials (no withholding required, skip to □ Other (Describe) Certification of Nonresident Payee) If the nonresident payee performs all the services within California, withholding is required on the entire payment for services unless the payee is granted a withholding waiver from the Franchise Tax Board (FTB). Please complete For more information, get FTB Pub. 1017, Resident and Nonresident Withholding Guidelines. Part IV Income Allocation Gross payments expected from the form and submit to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Broker/Agency Information Broker/Agency Name: Tax ID Number: I authorize CoPower to initiate electronic credit entries each commission pay period and, if necessary, debit entries and adjustments for any credit entries in error to my account. I acknowledge that withholding agent during the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it in writing. Broker/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: Date: / / Name: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx Xxxx. Suite 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • E-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxxcalendar year for:

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency Direct Deposit Authorization Form Use this form to enroll in direct deposit. Please complete the form and submit to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Broker/Agency Information Broker/Agency Name: Tax ID Number: I authorize CoPower to initiate electronic credit entries each commission pay period and, if necessary, debit entries and adjustments for any credit entries in error to my account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it in writing. Broker/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: Date: / / Name: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx XxxxXxxx Xx. Suite Xxxxx 000, Xxx XxxxxXxxxx Xxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • E-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxx00000

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRAXXX, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency Direct Deposit Authorization Form Use this form to enroll in direct deposit. Please complete the form and submit to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Broker/Agency Information Broker/Agreement DIRECT DEPOSIT COMMISSION Producer Code: Agency Name: Tax ID NumberStreet Address: City: State: FL Zip Code: I hereby authorize CoPower Cabrillo Coastal General Insurance Agency, LLC. (hereinafter referred to initiate electronic as Cabrillo) to instruct the bank named below to present Automated Clearing House (ACH) credit entries each to our Agency’s bank account described below for commissions owed to our Agency. In the event that an error is made and too much commission pay period and, if necessary, debit entries and adjustments for any credit entries in error is credited to my account. , I acknowledge that agree to promptly return the origination amount of ACH transactions such overpayment to my account must comply with the provisions of U.S. lawCabrillo. This authority will is to remain in full force and effect until I Cabrillo and Depository have cancelled it each received written notification from me, or another person so authorized by our Agency, of its termination. Notice will be in writingsuch time and manner as to afford a reasonable opportunity to act on it. Broker/Agency Information Accountholder’s Bank Name: Financial InstitutionAddress: Routing/City: State: FL Zip Code: Bank Phone Number: Contact: Bank ABA Number: Account Number: Financial Institution City Checking  Savings Signature of Agency’s Authorized Representative: State: Zip: Signature Signature: Date: / / NamePrint Name of Person Signing Above: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx XxxxIMPORTANT! Please attach a copy of a voided check to verify proper bank information. Suite 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • E-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxxDIRECT DEPOSIT FORM Revised 6.10.13

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Broker/Agency Direct Deposit Authorization Form Use TAXABLE YEAR Nonresident Withholding CALIFORNIA FORM 2023 Allocation Worksheet 587 The payee completes this form and returns it to enroll the withholding agent. The withholding agent keeps this form with their records. Part I Withholding Agent Information Withholding agent’s name City of Sacramento Address (apt./ste., room, PO box, or PMB no.) City (If you have a foreign address, see instructions.) State ZIP code Part II Nonresident Payee Information Xxxxx’s name □ SSN or ITIN □ FEIN □ CA Corp no. □ CA SOS file no. Address (apt./ste., room, PO box, or PMB no.) City (If you have a foreign address, see instructions.) State ZIP code Nonresident payee’s entity type: (Check one) • Individual/sole proprietor • Corporation • Partnership • Limited liability company (LLC) • Estate or trust Part III Payment Type Nonresident payee: (Check one) □ Performs services totally outside California (no withholding required, skip to □ Provides goods and services in direct depositCalifornia (see Part IV, Income Allocation) Certification of Nonresident Payee) □ Provides services within and outside California (see Part IV, Income Allocation) □ Provides only goods or materials (no withholding required, skip to □ Other (Describe) Certification of Nonresident Payee) If the nonresident payee performs all the services within California, withholding is required on the entire payment for services unless the payee is granted a withholding waiver from the Franchise Tax Board (FTB). Please complete For more information, get FTB Pub. 1017, Resident and Nonresident Withholding Guidelines. Part IV Income Allocation Gross payments expected from the form and submit to CoPower via E-mail at xxxxxxx.xxxxxxxxxxxxx@xxxxxx.xxx or via fax at 000.000.0000 Broker/Agency Information Broker/Agency Name: Tax ID Number: I authorize CoPower to initiate electronic credit entries each commission pay period and, if necessary, debit entries and adjustments for any credit entries in error to my account. I acknowledge that withholding agent during the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it in writing. Broker/Agency Information Accountholder’s Name: Financial Institution: Routing/ABA Number: Account Number: Financial Institution City: State: Zip: Signature Signature: Date: / / Name: Title: Attach Voided Check CoPower • 0000 X. Xxxxxxxxx Xxxx. Suite 000, Xxx Xxxxx, XX 00000 Phone: 000.000.0000 • Fax: 000.000.0000 • E-mail: xxxxxxx.xxxxxxxx@xxxxxx.xxxcalendar year for: