1. 1. Account Setup
  2. 2. Capital Agreement
  3. 3. ACH Authorization (current step)
  4. 4. Document Upload
LL
Loan Lama Capital
Advisory Services

ACH Authorization &
Payment Authorization Form

Client business name: HM Nationwide Health Advisors LLC
Email: hasnain@hmnationwide.com
Authorized signer: Hasnain Moti (Managing Director)
Phone: (954) 555-0123
1

Bank account details

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2

Authorization terms

1. Authorization

The Client authorizes Loan Lama Capital to initiate electronic debit entries (ACH) to the bank account identified in this form for advisory fees and any amounts due under the Capital Advisory Agreement.

2. Amount & Timing

Debits will be initiated only for amounts invoiced under the Capital Advisory Agreement and on the schedule stated in that agreement. The Client will be notified of any change in amount or date at least ten (10) days in advance.

3. Insufficient Funds

If a debit is returned for insufficient funds, the Client remains responsible for the amount due plus any return fee assessed by the Client's financial institution and a processing fee of $35.

4. Accuracy of Information

The Client certifies that the bank routing and account numbers provided are accurate and that the signer is authorized to bind the business named in this form.

5. Revocation

This authorization shall remain in effect until all advisory fees have been paid in full. Revocation must be submitted in writing and does not relieve the Client of any outstanding obligations.

3

Electronic signature

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