* * * CONFIDENTIAL * * *

If you have been promised money, yet not yet received these funds from Local Motion, Please complete this form and attach any supporting emails, text, audio recordings to support your Claim. Payments to any current or back pay will be reviewed, verified and confidentially awarded.

I (we) hereby known as “Requester” authorize netsirv, LLC, to initiate Local Motion MN, Inc. credit entries to the Requester checking or savings account indicate at the depository financial institution named below, hereafter called DEPOSITORY, and to credit the same to such account. Requester acknowledge that the Claim for Check Request is a valid Local Motion MN, Inc. payroll, compensation, reimbursement, or promise to pay back-pay that comply with provisions of US law.

Depository Financial Institution

Transfer Details

If you would like the amount of your claim deposited in your account, please complete the following. Otherwise a check, if approved, will be issued in you our your companies name and send to the above address.

This authorization is to remain in full force and effect until COMPANY has received written notification from Requester of its termination of this agreement in such time and in such manner.  The undersigned Requestor agrees to be bound by the NACHA Operation Rules, as amended and in effect from time to time.

NOTE: All written Requester Check claims must provide that the company may revoke the authorization that it deems fit and with sufficient supporting documentation.