AUTHORITY TO DEDUCT NAME TERM —[__] Three Months [J Others: _ RANK DEDUCT [| Self-Allotment VESSEL FROM —[_] Others: Acct. Name Acct. No. Bank hereby authorize SOUTHFIELD AGENCIES, INC. to deduct the following cash advances from my salaries/allotments: PARTICULARS AMOUNT, LOAN REASON: FOR DEPOSIT TO BELOW ACCOUNT NAME. BANK : ACCOUNT NUMBER TOTAL Any amount due and owing to SOUTHFIELD AGENCIES, INC. at the time of my termination, regardless of whether such termination was voluntary or not, shall be deducted from any remaining salaries/allotments due to me. | further understand and agree that such deductions shall be made after any mandatory government taxes and other such required payments are complied with under the law. |1am fully aware that the authorized deductions shall be done in accordance with the agreed and written terms and conditions of my availment. | further declare that this authorization is voluntarily signed, with full knowledge that this is an obligation | am legally bound to repay. SEAFARER Approved by: Signature Signature Name Name Date Date