To be stopped effective immediately upon receipt of this form.

ACH DIRECT DEPOSIT CANCELLATION AUTHORIZATION AGREEMENT
LOCATION\STORE#: _________________
I (we) hereby authorize __EARTH FARE_, hereinafter called COMPANY, to initiate
cancellation to my (our) Checking ________ Savings _______ account
indicated below and the depository named below, hereinafter called
DEPOSITORY, to credit (or debit) the same to such account.
CANCEL Account(s):
_______________________________________________________________
BANK NAME/BRANCH
CITY
STATE ZIP CODE
________________________________________________________________
BANK TRANSIT/ABA NUMBER (attached voided check) ACCOUNT NUMBER
To be stopped effective immediately upon receipt of this form.
_______________________________
EMPLOYEE NAME(S)
_______________________________
SOCIAL SECURITY(last four digits)
_______________________________
EMPLOYEE SIGNATURE
DATE
________________________________
SIGNATURE
DATE
(if someone other than employees account)
Processed Date: _________________
Processed By: _____________________________________