DISBURSEMENT AUTHORIZATION

TO: Balboa Capital Corporation

The undersigned hereby certifies that all the property described below (the "Equipment") which is to be financed for the
undersigned pursuant to the Equipment !inancing "greement #o$ _____________dated as of (the
""greement") between Balboa Capital Corporation and the undersigned as %ebtor has been furnished to the
undersigned that deli&ery and installation has been fully completed and that the Equipment is acceptable in all respects to
the undersigned$
'n &iew of the abo&e the undersigned hereby authori(es and requests you to pay for the Equipment in accordance with the
terms of any purchase orders the undersigned may ha&e issued for the same and)or to pay the undersigned the ad&ance
amount to the e*tent the undersigned has pre&iously paid for the Equipment as appropriate$ The undersigned
ac+nowledges that you are relying upon this e*ecuted %eli&ery and "cceptance Certificate in so doing$ %ebtor hereby
authori(es Creditor to disburse the Total "d&ance as follows:
,ayee #ame "mount
______________________________________________________________________ ______________
______________________________________________________________________ ______________
______________________________________________________________________ ______________
______________________________________________________________________ ______________
Total "mount to be %isbursed ______________
EQUIPMENT - SEE EXHIBIT "A" ATTACHED HERETO AND MADE A PART HEREOF.
The undersigned recogni(es that by e*ecuting this %eli&ery and "cceptance Certificate the undersigned-s non.terminable
installment payment obligation under the "greement will commence$ The undersigned reaffirms its understanding that
the "greement is solely a financing agreement and that accordingly you ha&e made no e*press warranties as to the
Equipment of any other matter and that there are no related implied warranties created by law and further that
accordingly the undersigned/s obligation to pay amounts due under the "greement will not be affected by any problems
the undersigned e*periences with the Equipment or any similar or dissimilar occurrence as also set forth in the
"greement$
%ate Equipment accepted by %ebtor (Acceptance Date)
(%ate)
Email Address or In!oi"in#$ 0000000000000000000000000000000000000000000000000000000
%a& N'mber or In!oi"in#$ 000000000000000000000000000000000000000000000000000000000
Cell N'mber: 00000000000000000000000000000000000000000000000000000000000000000000
Attention To: 00000000000000000000000000000000000000000000000000000000000000000000
"Delivery of thi !o"#$e%t &e'ri%( ' f'"i$ile i(%'t#re or i(%'t#re h'll h've the '$e
for"e '%! e)e"t ' if the !o"#$e%t &ore '% ori(i%'l i(%'t#re."
Debtor Name$ _____________________________________________________________________________
B($ __________________________________________
Name$ ________________________________________
Title$ _________________________________________ Date$ ___________________________
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