Account Number Form

ACCOUNT NUMBER FORM

This Account Number Form and accompanying agreement (the Agreement) is entered into by the parties identified below for the purpose of establishing, authorizing, and maintaining account information for use in connection with the provision of services described herein.

Parties

Client Name:

Service Provider Name:

WHEREAS Recitals

WHEREAS, Client maintains one or more financial accounts for which Client desires the Service Provider to retain account information for authorized debits and credits in connection with services to be provided; and

WHEREAS, Service Provider requires accurate account details and written authorization from Client to initiate electronic transfers, billing, or other payment processing against such account; and

WHEREAS, the parties intend that this Account Number Form serve as an integrated agreement documenting account data, authorization, payment terms, and confidentiality obligations.

Scope of Work

Account Details

Routing Number:    Account Number:

Account Holder Name:

Checking    Savings    Other:

Authorization and Use of Account Information

Client hereby authorizes Service Provider to retain and use the account information provided above, and to initiate debit and credit entries and adjustments to the account as necessary to effect payments for services rendered under this Agreement. This authorization is a continuing authorization until revoked in writing in accordance with the Term and Termination provisions below.

Authorization Type:    Authorize ACH debit    Authorize credits

Client affirms that the account information submitted is true and correct and agrees to notify Service Provider in writing of any changes at least days prior to the next scheduled transaction.

Payment Terms

Amount Payable per Invoice/Service: $

Payment Schedule:

Late Fee: . Client is responsible for all fees, charges, and collection costs incurred by Service Provider as a result of late or returned payments.

Payment Method: Automated debit from account on file    Invoice billing

Term and Termination

Term Commencement Date:    Term Expiration Date (if applicable):

Either party may terminate this Agreement for convenience with prior written notice of days. Termination does not relieve Client of obligations for payments due for services rendered or transactions initiated prior to termination.

Confidentiality

Each party acknowledges that account information and payment details are confidential and proprietary. Service Provider shall protect and limit access to Client account information, shall use such information only for authorized purposes under this Agreement, and shall not disclose such information except as required by law, regulation, or as necessary to effect authorized transactions. Standard commercially reasonable safeguards and access controls shall be maintained.

Representations, Warranties and Liability

Client represents that it is authorized to provide the account information and to permit debits and credits to the account. Service Provider will exercise reasonable care in handling account data but shall not be liable for losses arising from inaccurate account information provided by Client, untimely notice of changes, bank processing delays, or acts beyond Service Provider's reasonable control. Service Provider's liability for direct damages arising from its negligence is limited to actual proven damages not to exceed the aggregate fees paid by Client to Service Provider under this Agreement during the preceding six months.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to conflict of laws principles.

Entire Agreement

This Account Number Form, together with any schedules and attachments executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior negotiations, understandings, and agreements. Any amendment must be in writing and signed by authorized representatives of both parties.

Notices

Certification and Warranty

By signing below, Client certifies that the account information provided is correct, that Client is the authorized signatory for the account, and that Client authorizes Service Provider to initiate transactions as specified. Client acknowledges that submission of this form constitutes a binding authorization and warranty.

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