Business AR Request Form

BUSINESS AR REQUEST FORM

Requesting Party:    Service Provider:

RECITALS

WHEREAS, Requesting Party requires collection, recovery, administration, and related accounts receivable services in respect of certain outstanding invoices and receivables; and

WHEREAS, Service Provider is duly experienced and authorized to perform accounts receivable collection, reconciliation and recovery services, and Requesting Party desires to retain Service Provider under the terms and conditions set forth in this document;

NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties agree as follows and acknowledge that the information supplied on this Business AR Request Form is a material part of that agreement.

PARTY CONTACT INFORMATION

DEBTOR / CUSTOMER INFORMATION

INVOICE(S) TO BE HANDLED

Provide itemized invoices. Attach supporting copies as indicated below.

SUPPORTING DOCUMENTS (CHECK ALL PROVIDED)

Invoice copy Signed contract or purchase order Delivery receipt / proof of service Correspondence / dunning history Court or litigation documents

SCOPE OF WORK

Describe the precise services to be provided by Service Provider with respect to the accounts and invoices listed, including any limitations, escalation steps, or litigation authority.

PAYMENT TERMS

TERM AND TERMINATION

This Agreement commences on and continues until unless earlier terminated as provided below.

Either party may terminate for convenience upon days' prior written notice. Termination does not relieve Requesting Party of obligations to pay fees earned and expenses reasonably incurred by Service Provider prior to termination.

CONFIDENTIALITY

Each party shall treat as confidential all non-public information disclosed in connection with this AR request and the services provided (Confidential Information). Confidential Information shall not be disclosed to third parties except as reasonably necessary to perform this Agreement, to enforce rights hereunder, or as required by law. Confidential Information shall be used solely for the purposes of collection and recovery of the specified receivables. The obligations of confidentiality shall survive termination for a period of three years.

GOVERNING LAW

This Agreement and any dispute arising out of it shall be governed by and construed in accordance with the laws of the state of , without regard to choice-of-law principles.

ENTIRE AGREEMENT

This Business AR Request Form, together with any schedules, attachments and the written terms accepted by the parties, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior or contemporaneous understandings, representations, and agreements, whether written or oral. No modification of this Agreement is effective unless in writing and executed by authorized representatives of both parties.

CERTIFICATION AND AUTHORIZATION

By checking the box below and signing this form, Requesting Party certifies that it is the lawful owner of the accounts and invoices listed or is otherwise authorized to request collection or assignment of such accounts, that the amounts and supporting documentation provided are true and correct to the best of its knowledge, and authorizes Service Provider to undertake collection efforts, pursue legal action if authorized in the Scope of Work, and take such reasonable actions as necessary to recover the receivables.

I certify the foregoing and authorize Service Provider to act as described above.

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