Authorization Extract Form

AUTHORIZATION EXTRACT FORM

Effective Date:

Parties

WHEREAS

WHEREAS, Authorizing Party named above is the lawful owner or custodian of records, documents, or data described in this form and possesses authority to permit disclosure of extracts of such records; and

WHEREAS, Authorized Recipient is engaged to obtain, compile and deliver an extract of specified records on behalf of Authorizing Party for the purposes set forth below; and

WHEREAS, the parties wish to set forth the scope, fee arrangement, confidentiality obligations and other terms under which such extract will be prepared and delivered.

Scope of Work

Authorized Recipient shall prepare and deliver an extract consisting of the records and data described below. The extract shall be limited to the purpose stated and formatted as agreed between the parties.

Types of extract authorized (select all that apply):

Corporate registry extract Property title extract Bank/account statement extract

Employment or payroll records Other (specify)

Payment Terms

In consideration for services rendered by Authorized Recipient, Authorizing Party agrees to pay the fees set forth below in accordance with this Payment Terms section. Fees payable are exclusive of any taxes for which Authorizing Party shall remain responsible.

All fees unpaid within five (5) business days after the due date shall accrue the stated late fee and may result in suspension of delivery until payment is received. Costs of collection, including reasonable attorneys' fees, shall be recoverable by the prevailing party.

Term and Termination

This authorization commences on and terminates on unless earlier terminated in accordance with this section.

Either party may terminate this authorization for material breach if the breaching party fails to cure such breach within the notice period specified above. Termination shall not relieve the Authorizing Party of its obligation to pay fees accrued through the date of termination.

Confidentiality

The parties acknowledge that extracts may contain confidential, proprietary, or personally identifiable information. Authorized Recipient shall maintain such information in strict confidence, shall use it solely for the purposes set forth in this form, and shall not disclose such information to any third party except as necessary to perform the services and subject to comparable confidentiality obligations. Authorized Recipient shall implement reasonable administrative, technical and physical safeguards to protect the confidentiality and integrity of the data.

If disclosure of confidential information is required by law or valid legal process, Authorized Recipient shall provide prompt written notice to Authorizing Party (to the extent legally permitted) and shall cooperate to seek protective measures.

Governing Law

This Authorization Extract Form 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 form, together with any exhibits or attachments expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, understandings or agreements, whether written or oral. Any amendment must be in writing and signed by both parties.

Authorization and Certification

By signing below, Authorizing Party certifies that it has full authority to grant the rights and permissions set forth herein and hereby authorizes Authorized Recipient to obtain the authorized extract for the stated purpose. Authorized Recipient accepts the obligations set forth in this form and agrees to perform in accordance with its terms.

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