Account Release Request Form

ACCOUNT RELEASE REQUEST FORM

WHEREAS

WHEREAS, Account Holder: is the lawful owner of the account identified below and seeks authorization to release funds, records, or assets held in that account; and

WHEREAS, Requesting Party: (the recipient) represents that it is entitled to receive such release upon satisfaction of the conditions set forth in this form and any accompanying documentation; and

NOW, THEREFORE, in consideration of the mutual covenants and promises contained herein, Account Holder and Requesting Party agree as follows:

REQUEST DETAILS

Account Type: Individual Corporation Trust Other

SCOPE OF WORK

Describe the precise items, funds, records, or assets to be released, including any account sub-ledgers, statements, or instruments and any conditions precedent to release:

PAYMENT TERMS

Processing Fee Amount:

Late Fee for Overdue Payments:

All fees must be paid in full prior to the requested release unless otherwise agreed in writing. Fees and payment obligations survive termination of this agreement until satisfied.

TERM AND TERMINATION

Effective Date:    Termination Date (if applicable):

Notice Period for Termination (days):

Either party may terminate this request upon written notice to the other if a material breach is not cured within the notice period. Obligations incurred prior to termination, including payment obligations and confidentiality obligations, shall survive termination.

CONFIDENTIALITY

The parties acknowledge that information exchanged in connection with this release may be confidential. Each party shall: (a) use confidential information solely for the purposes of effecting the release; (b) restrict disclosure to employees or agents with a need to know; and (c) employ reasonable safeguards to protect such information. Confidentiality obligations shall survive termination for a period of five (5) years or as otherwise required by applicable law.

REPRESENTATIONS, WARRANTIES, AND AUTHORIZATION

The Account Holder represents and warrants that it is authorized to request the release and that no legal restrictions, liens, or adverse claims prevent the requested release as described. The Requesting Party represents that it is acting for legitimate purposes and will provide any required identification or documentation upon request.

By signing below, Account Holder expressly authorizes the Financial Institution and any relevant custodian to release the specified assets to Requesting Party upon satisfaction of the conditions set forth herein.

AUTHORIZATION TO RELEASE

Release Amount (if monetary): . Release Method: .

Release To (Name/Entity): ; Release To Address:

ATTACHMENTS AND REQUIRED DOCUMENTS

Attachments provided with this request (select all that apply):

Government-issued photo ID Proof of authority (power of attorney, corporate resolution) Signed agreement or order Other (specify in Notes)

GOVERNING LAW

This Request and any dispute arising out of or relating to it shall be governed by and construed in accordance with the laws of the jurisdiction specified by the parties below without regard to its conflict of law principles.

Governing Jurisdiction:

ENTIRE AGREEMENT

This form, together with any attachments and written amendments executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written.

ACKNOWLEDGMENT

The undersigned certify that they are authorized to execute this Account Release Request Form on behalf of the party for which they sign, that the information provided is true and correct to the best of their knowledge, and that they consent to the release described above subject to the terms herein.

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