Bank Account Certification Form

Bank Account Certification Form

WHEREAS

WHEREAS, Company Name: is entering into this Banking Certification and Payment Agreement with Account Holder: ;

WHEREAS, the parties desire to establish a certified deposit account for the purpose of effecting electronic funds transfers, automatic payments, refunds, or other payments in accordance with the Payment Terms below.

CERTIFICATION OF ACCOUNT DETAILS AND AUTHORIZATION

By executing this form, the Account Holder certifies under penalty of perjury that the bank account information provided below is complete, true, and accurate, that the Account Holder is an authorized signer on the account, and that the Account Holder authorizes Company Name to initiate debit and credit entries to the specified account for amounts consistent with the Payment Terms and scope of services set forth in this Agreement.

BANK ACCOUNT INFORMATION

Voided check or bank letter attached: Yes

SCOPE OF WORK

Describe the goods and/or services, and the relationship of payments to deliverables. Include billing cadence and any invoicing reference numbers.

PAYMENT TERMS

Amount to be deposited or debited: $   Schedule:

Late payment fee: $   Returned item fee: $

All payments authorized herein may be initiated by Company Name and the Account Holder authorizes the depository financial institution to accept such entries and to debit or credit the designated account. Account Holder agrees to promptly notify Company Name of any change in account information by written notice not less than prior to the effective date of the change.

TERM AND TERMINATION

This certification and payment authorization is effective as of Start Date: and shall continue until End Date: or until terminated in accordance with the notice requirements below.

Either party may terminate this authorization upon written notice delivered to the other party not less than days prior to the desired termination date. Termination will not affect obligations or authorizations for transactions initiated prior to termination.

CONFIDENTIALITY

Each party shall maintain in confidence all non-public financial and account information obtained from the other party in connection with this certification, and shall not disclose such information except to its employees, agents, or professional advisors who have a need to know and who are bound to maintain confidentiality. This obligation shall survive termination of this Agreement.

WARRANTIES, INDEMNIFICATION, AND LIMITATION

The Account Holder warrants that it is authorized to provide the account information and to permit Company Name to debit and credit the account as specified. The Account Holder shall indemnify, defend and hold harmless Company Name from and against any claims, losses or liabilities (including reasonable attorneys' fees) arising from inaccurate account information, unauthorized transactions initiated by the Account Holder, or the Account Holder's failure to notify Company Name of changes.

GOVERNING LAW

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

ENTIRE AGREEMENT

This document constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements, representations, and understandings, whether written or oral. No amendment or modification shall be effective unless in writing and signed by both parties.

ACKNOWLEDGMENT AND SIGNATURES

The undersigned certify that they are authorized to execute this Bank Account Certification Form on behalf of the party they represent, that the information provided is true and complete, and that they authorize the banking transactions and certifications described herein.

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