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, as follows: Account Name Payable To Mailing Address of Recipient (if applicable) Picked up by (if applicable) This check should be processed as a instructions, this authorization expires two years from the effective date. (monthly, quarterly, one-time) check. If these are standing By signing below, I certify that the instructions I have provided and/or examined on this form are accurate and complete. Sincerely, Client s Name Signature Date Client s Name Signature Date NY.

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