Payor information:

Name: Address: City: Province: Postal Code: Telephone number:

You, the above-noted Payor authorized Sheila Smelt & Associates Inc. (SSA) to make deductions through the financial institution set out below (or any other financial institution which you may authorize at any time). Please attach a void cheque.

Account number: ChequingSavings Transit number: Financial Institution number: Financial Institution Name: Address:

You, the above-noted Payor agree that the payments shall be for all amounts due for proceedings under the Bankruptcy & Insolvency Act (BIA) filed through SSA. Regular payments for the full amount due under the BIA proceedings will be debited from the specified account (or any other account which you may authorize at any time) on the date set out below. You, the above-noted Payor agree to waive the 10 day pre-notification period. Should you instruct SSA by mail, email or fax to change the financial institution, payment amount, number of payments and/or the date of any of the payments due under the Authorization, you also agree to waive the 10 day pre-notification period.

You, the above-noted Payor understand that you may change or cancel this agreement at any time by contacting SSA in writing or by email at least 5 business days before the next withdrawal and you understand that the cancellation of this authority does not release you from any obligations under the BIA. For further information regarding your rights refer to www.cdnpay.ca.

Payment Amount: 10th of the month20th of the month Date of first payment: Total number of payments: Date of last payment: Date: