Banking Account Details Form

Banking Account Details and Payment Authorization Agreement

Parties and Recitals

This Banking Account Details and Payment Authorization Agreement (the "Agreement") is entered into by and between:

Company Name:

Company Address:

Client Name:

Client Address:

WHEREAS, the Company provides certain goods and/or services to the Client as described in the Scope of Work below; and

WHEREAS, the Client desires to provide banking account information to facilitate payments and to authorize the Company to initiate credits and, where applicable, debits to the designated bank account in accordance with the Payment Terms in this Agreement.

NOW, THEREFORE, in consideration of the mutual promises contained herein, the parties agree as follows:

Banking Account Details

Individual Business

Checking Savings Other:

Yes

Authorization

By signing below, the Account Holder authorizes the Company to initiate credits to the bank account identified above for amounts due under this Agreement. Where applicable and permitted by law, the Account Holder further authorizes the Company to initiate debit entries and adjustments for any payments made in error or for returned items, subject to the Payment Terms set forth below. This authorization will remain in effect until the Company receives written notice of revocation at the address listed above and has had a reasonable opportunity to act on such notice.

Scope of Work

Payment Terms

Amount per Invoice/Contract:

Late Payment Fee:

Payment Method (check all that apply): ACH / Direct Deposit Wire Transfer Check

Term and Termination

Contract Start Date:

Contract End Date (if any):

Termination Notice Period (days):

Either party may terminate this Agreement for convenience upon providing the notice period above in writing. Termination will not relieve the Client of obligation to pay for services rendered and expenses incurred prior to termination, nor will it relieve the Client of any amounts properly charged to the Account pursuant to this Agreement.

Confidentiality

Each party shall hold confidential all non-public information obtained from the other party in connection with this Agreement, including banking information, payment data, and pricing, and shall not disclose such information except as required by law or with the prior written consent of the disclosing party. This obligation survives termination of this Agreement.

Representations, Warranties and Indemnity

The Account Holder represents and warrants that it is authorized to provide the banking information above and to authorize debits and credits to the account. The Account Holder agrees to indemnify and hold harmless the Company from any claims, losses, or liabilities arising from inaccurate account information or the Account Holder's failure to notify the Company of changes to the account.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the state indicated below without regard to conflict of law principles.

Entire Agreement

This Agreement, together with any attachments and the Scope of Work, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether written or oral.

Account Verification and Change Notification

The Account Holder agrees to notify the Company promptly of any change in account information. The Company may verify the account details and may require a cancelled check or bank letter to confirm the account prior to initiating payments.

Certification

I certify that the information provided on this form is true and correct to the best of my knowledge, that I am authorized to provide the information and to grant the authorizations set forth herein, and that I will notify the Company immediately of any changes.

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