Authority Permission Form

AUTHORITY PERMISSION FORM

This Authority Permission Form is entered into by the parties identified below to establish the scope and limitations of authority granted by Principal Name: to Authorized Representative Name: with an Effective Date: .

WHEREAS

WHEREAS, Principal is the legal owner of certain rights, records, interests and matters described herein and requires the assistance of an authorized representative to act on Principal's behalf in limited matters;

WHEREAS, Agent represents that Agent has the competence, authority and legal capacity to perform the actions set forth below and that Agent will act in good faith and in Principal's best interests within the scope granted; and

WHEREAS, Principal desires to delegate specific authority to Agent for the purposes described in this Form subject to the terms, limitations and conditions herein.

PARTIES AND CONTACT INFORMATION

SCOPE OF AUTHORITY

Principal hereby grants Agent the limited authority to act as described in this Scope of Authority. The authority granted is strictly limited to the purposes and limitations set forth in this section and any attachments incorporated by reference.

Specific authorities granted (select all that apply and describe any limitations):

Access, inspect and obtain records, reports and documents related to Principal

Sign and execute documents on Principal's behalf where law permits

Collect, receive and remit funds or payments on Principal's behalf

Represent Principal before third-party vendors, service providers or institutions

Other (describe)

PAYMENT TERMS

If compensation is payable to Agent for services under this Form, the terms are as follows:

TERM AND TERMINATION

The authority granted under this Form shall commence on Start Date: and shall expire on End Date: unless earlier revoked or terminated in accordance with this section.

Either party may terminate this Form for any reason by providing the written notice specified above. Termination does not relieve the parties of obligations incurred prior to the effective date of termination.

CONFIDENTIALITY

Agent shall maintain in strict confidence all non-public information obtained from Principal in connection with the exercise of authority hereunder. Agent shall not use, disclose or permit the use or disclosure of such information except (a) to perform duties authorized by this Form; (b) as required by law, valid subpoena, court order or regulatory request; or (c) with Principal's prior written consent. Agent shall employ reasonable safeguards to protect Confidential Information from unauthorized access or disclosure.

For purposes of this Form, "Confidential Information" includes financial records, account numbers, personal identification information and other non-public business or personal information obtained by Agent in connection with the authority granted.

LIMITATIONS AND EXCLUSIONS

REPRESENTATIONS AND WARRANTIES

Principal represents and warrants that Principal is legally entitled to grant the authority described herein and that no third-party consent or authorization is required other than those disclosed to Agent in writing. Agent represents and warrants that Agent will act within the scope of authority granted and in accordance with all applicable laws and regulations.

GOVERNING LAW

This Form shall be governed by and construed in accordance with the laws of the jurisdiction selected by the parties. Any dispute arising from or related to this Form shall be resolved in the courts of that jurisdiction unless the parties agree otherwise in writing.

ENTIRE AGREEMENT

This Form 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. Any amendment or modification to this Form must be in writing and signed by both parties.

CERTIFICATION

By signing below, Principal certifies under penalty of perjury that the information provided herein is true and correct, that Principal authorizes the Agent to perform the duties described to the extent permitted by law, and that Principal understands the limitations and duties imposed on the Agent by this Form.

I acknowledge that the authority granted may include the power to access sensitive or personal information and that misuse of the authority may subject Agent to civil and criminal liability.

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