Date

To Whom It May Concern,

I,

of (Company Name), herein authorizes,

(Name of Bank)

(Address)

Bank Phone # Bank Contact Person

to release to a duly authorized representative of the New York City TRANSIT Metrocard RETAIL Sales a duly authorized representative of the MTA NYC Transit, MetroCard Retail Sales program, any information requested in respect to my account(s) for Official Use by the New York City Transit Authority. Should there be any questions as to the validity of this release, you may contact me directly.

Account Number:

Routing Number:

Signature: ___________________________________________

Telephone: