Authority Change Request Form

AUTHORITY CHANGE REQUEST FORM

Parties and Identification

Requesting Party Name:

Recitals

WHEREAS, the Requesting Party maintains accounts, authorizations, or delegated authorities with the Receiving Organization identified above; and

WHEREAS, the Requesting Party desires to modify, add, or revoke certain authorized individuals or levels of authority and the Receiving Organization requires written authorization per its policies and applicable agreements; and

WHEREAS, the Receiving Organization is willing to effectuate the requested authority changes upon receipt of this completed Authority Change Request Form and any required supporting documentation.

Requested Changes

Effective Date:

Current Authorized Individual(s) (Name — Title — Authority Level):

Requested Change to Authorization (Add / Modify / Revoke). For each entry, provide full name, title, identifier (e.g., employee ID), and specific authority being granted or removed:

The Requesting Party confirms the following attachments are provided as required (check all that apply):

Corporate Resolution or Board Minutes

Identification Documents for New Individuals

Other (specify below)

Scope of Work / Effect of Change

Describe the operational scope, responsibilities, or transaction types affected by this authority change. Include any limits, conditions, or systems access impacted:

Payment Terms (If Applicable)

If the requested authority change triggers fees, specify the amount, payment schedule, and late fee policy.

Term and Termination

Start Date:    End Date (if any):

Either party may terminate this authority or this request prior to the effective date or thereafter for material breach or by providing notice in writing. Minimum notice required:

Upon termination, Receiving Organization shall suspend or revoke the specified authorities and may require return of credentials, access tokens, or other materials.

Confidentiality

Each party shall maintain in confidence all nonpublic information received in connection with this request and shall not disclose such information except to employees, agents, or contractors who have a need to know and who are bound by confidentiality obligations no less protective than those contained herein. Confidential information does not include information that is or becomes publicly available through no fault of the receiving party, is independently developed, or is rightfully received from a third party without restriction.

Representations, Warranties and Certification

The Requesting Party represents and warrants that the person executing this form is duly authorized to request the changes specified herein. The Requesting Party certifies that all information provided is true, complete, and accurate and agrees to indemnify and hold harmless the Receiving Organization for any losses arising from false or misleading information or lack of authority to make this request.

Governing Law; Entire Agreement

This Authority Change Request shall be governed by and construed in accordance with the laws of the State of , without regard to choice of law principles.

This form, together with any attachments referenced herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior communications, representations, or agreements, whether written or oral.

Additional Provisions

Notices required under this form shall be in writing and delivered to the addresses provided above. Any modification to this request must be made in writing and signed by an authorized representative of both parties.

Acknowledgment and Signature

By signing below, the undersigned certifies under penalty of perjury that they are authorized to execute this Authority Change Request on behalf of the identified Requesting Party and that the information provided is accurate. The Receiving Organization's signature acknowledges receipt and acceptance to implement the requested changes subject to verification.

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