AUTOMATED ELECTRONIC FUNDS TRANSFER AUTHORIZATION

✘ New Request
Change to existing Payment Instructions (This agreement supersedes any existing agreement in place.)
Please Note Original Debit Account Number for Existing Agreement:
Terminate existing Payment Instructions (Please completed below to indicate transfer to be terminated.)
Originator Name (CNB Customer): Originator CIF:

Originator Address:

Transfer From: (Debit/Withdrawal) Transfer To: (Credit/Deposit or Payment)

Financial Institution Name: Financial Institution Name:
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ABA Routing Number: ABA Routing Number:

021000322

Account Number: Account Type: Account Number: Account Type:

483099683246 DEBIT

Is Originator an Owner or Signer on this DEBIT account? (Y or N): Is Originator an Owner or Signer on this CREDIT account? (Y or N):
Debit Account Owner Name: tatia nebieridze Credit Account Owner Name:
*** If the CNB client originating this transfer is not an Owner or Signer on either the DEBIT or CREDIT account, an Authorization Agreement for ACH
Debit or Credit form is required to be completed and signed by the third party client before the transfer can be established. ***
FOR CNB LOAN PAYMENTS ONLY:
Regular Payment - Payable ONCE per MONTH beginning on (Date): and continuing on the same day until maturity. *
*Last payment amount due on obligation may v ry.
Extra Principal Payment - Amount: Select frequency
* If f extra principal payments will on the payment due date.
Skip Transfer Option: Skip transfer on Date: Number of transfers to skip: Resume transfer Date:

Transfer Amount: First Transfer Date: (please allow five (5) business days for processing)

Please select transfer frequency: Weekly - Every Seven (7) Days Bi-Weekly - Every Fourteen (14) Days
Semi-Monthly - On the day and the day of the month.

✘ Monthly Quarterly Other:

Skip Transfer Option: Skip transfer on Date: Number of transfers to skip: Resume transfer Date:
Terms and Conditions:
Term of Request: This Request will expire on ____________________ (date). **If left blank, the Request will continue until modified in writing or terminated
in the manner described below.
Weekend/Holiday Transfers: If the date of the transfer is a Saturday, Sunday or Holiday, the transfer will not take place until the next business day.
Termination: I may terminate this request by notifying the Bank in writing. Notice is effective when received by the Bank. The Bank may terminate this request
by sending me written notice. Termination of the transfer request is effective immediately upon the Bank’s mailing of the notice to me.
Terms Subject to Available Funds: I agree to maintain sufficient available funds (that is, a sufficient balance in my deposit account or a sufficient amount of
available credit on my line of credit account, whichever is applicable) to cover the amount of each transfer described in the Request. I understand that the
transfer may not be made if the available funds are not sufficient to cover the amount of the transfer. In the event the Bank does not make the transfer due to
lack of sufficient available funds, I understand that the transfer will take place on the first day after the scheduled transfer date on which the account has
sufficient available funds, unless I provide notice of termination to the Bank as provided above.
Additional Information: I agree to supply the Bank promptly with all the information requested by the Bank pertaining to this request.
Additional Agreements: If the Request involves transfer of funds from a deposit account, it is subject to the terms and conditions of the agreement governing
my deposit account, including the Electronic Banking Services portion of this agreement and the disclosures required by Federal Regulations E. If this Request
involves transfer of funds from a credit account, it is subject to the terms and conditions of the agreement governing my line of credit account.
Indemnification: Unless otherwise provided in the applicable agreement described in the preceding paragraph, I agree to indemnify, defend, and hold the Bank
harmless against all cost, (including attorney’s fees), actions, damages, or claims related to or arising from the Bank’s actions pursuant to this Request
including claims by me or any payee for failure to transfer funds or transferring funds improper as a result of my providing incorrect information.

6/22/2024

Originator Signature Date Printed Name

For Bank Use Only:
Submitted by CNB Employee: #: Extension: CRM Event Must Be Completed
If transfer is from a CNB account to pay a CNB loan, scan All other requests, please scan to Synergy - Electronic Banking Cabinet
 Camden National Bank
Authorization Agreement for ACH DEBIT or CREDIT
Receiver (Third Party) Authorization
Originating Depository Financial Institution (ODFI)
Ca en National Bank
245 Commercial Street
Rockport, ME 04856
800-860-8821
ABA# / ACH Company ID: 011201458

Camden National Bank Customer Name:

Hereinafter called the "Originator".

Agreement

The Originator named above is hereby authorized to initiate the following recurring entry to my account as
indicated below, to debit or credit the same such account. In the event of an error the originator is hereby
allowed to make the appropriate adjusting entries so as to fix the specific error. I acknowledge that the
origination of ACH transactions to my account must comply with the provisions of U.S. law.

Receiving Depository Financial Institution (RDFI)

Financial Institution Name
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ABA# /Routing Number 021000322

Account Name tatia nebieridze

Account Number 483099683246

Account Type DEBIT

Amount of Transfer/Payment
Payment Type

Termination
This authorization is to remain in full force and effect until the Originator has received written notification
from me of its termination in such time and in such manner as to afford Originator and Originating Depository
Financial Institution a reasonable opportunity to act on it.

Authorization

6/22/2024 tatia nebieridze

Receiver (Third-Party) Signature Date Printed Name