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Benefit Express Services, LLC Technology and Services Agreement +, Exhibit B - Optional Payment Authorization — Monthly -Fees Please complete the appropriate section for your preferred method of payment. Please provide a photocopy of the credit card or voided bank check in lieu of the bank information below along with the signed copy of this form. I authorize Benefit Express Services, LLC to initiate monthly deduction from my account shown below, for the amount and period specified, for payment of monthly fees. Credit Card Information Client Name: .... Name on Card: .. ❑ Visa ❑ Mastersrd American Express Card Number: ".. .... .. .. . Security Code: Expiration Date: Billing Address: City: State, Postal Code: EFT Informati1011 Name on Account: Account Number: i Bank Name: 4 Bank Routing Number (9 digits): i Invoicing Information c Same as previous page t Company Billing Addre : Company Billing City: " Company Billing State: , Company Billing Postal Code: Billing Contact Name: Billing Contact Phone Number: Billing Contact Fax Number: Billing Contact Email Address: I understand this authority is to remain in full force and effective until Benefit Express Services, LLC has received written notification from me of its termination in such time and manner as to afford Benefit Express Services, LLC and depositor a reasonable opportunity to act upon it, I have the right to stop payment of deduction to my credit card or bank account by notification to Benefit Express Services, LLC thirty (30) business days or more before this payment is scheduled to be made. Signature: Date: J 83 i k