Business Purpose Verification Form

BUSINESS PURPOSE VERIFICATION FORM

WHEREAS

WHEREAS, Applicant Name: (the "Applicant") is engaged in the business set forth in this form and seeks to establish or maintain a commercial relationship with Verifier Name: .

WHEREAS, the parties require written verification of the Applicant's stated business purpose, source of funds, expected activity and related representations to satisfy contractual, compliance and risk management requirements.

NOW, THEREFORE, Applicant and Verifier set forth the following statements, representations and terms effective as of Effective Date: .

APPLICANT INFORMATION

Corporation Limited Liability Company (LLC) Partnership Sole Proprietorship Other:

BUSINESS PURPOSE STATEMENT

The Applicant certifies the primary nature of its business activity and the specific purpose for which the account or transaction is being requested. Provide a concise description of primary business activities and the business purpose for the relationship or transaction.

SCOPE OF WORK

If the business relationship contemplates services, sales, or other deliverables between Applicant and Verifier or related third parties, describe the scope of work, deliverables, and any material milestones. Include parties' obligations that bear on the purpose of account activity.

PAYMENT TERMS

The parties agree that payments made in connection with the services or transactions described herein shall be governed by the following terms. Applicant acknowledges and warrants that payment arrangements are lawful and consistent with the business purpose stated above.

Late Payment: Applicant agrees that late payments shall incur a late fee not to exceed the greater of the amounts specified below.

TRANSACTION PROFILE

International Activity: Yes No If yes, describe countries and expected frequency:

SOURCE OF FUNDS

Describe the expected sources of funds that will flow through the account or be used in the transaction (e.g., sales revenue, investor capital, loans, client receipts). Be specific about origin, regularity, and any third-party payors.

COMPLIANCE, REPRESENTATIONS AND WARRANTIES

The Applicant hereby represents and warrants that: (a) all information provided in this form is true, complete and correct to the best of Applicant's knowledge; (b) funds used in connection with the stated business purpose are derived from lawful activity; (c) Applicant will notify Verifier promptly of any material change to the information provided herein.

Beneficial Owners and Control Persons: Applicant certifies that it has identified all beneficial owners required under applicable policy and law. Provide name(s), title(s) and ownership percentage for each owner or attach supplemental list if necessary.

Applicant acknowledges that Verifier may rely on these representations in evaluating the Applicant and that false statements may be grounds for denial, account closure, or legal action.

TERM AND TERMINATION

This verification and any related agreement shall commence on Start Date: and continue until End Date: , unless earlier terminated.

Either party may terminate this verification or related services for convenience upon written notice given at least Notice Period (days): days prior to termination. Termination shall not affect obligations accrued prior to termination.

CONFIDENTIALITY

The parties agree that information provided in this form is confidential and may only be used for the purposes of compliance, underwriting, risk assessment and enforcing the parties' rights under any related contracts, except as required by law or valid governmental request. Each party shall implement reasonable safeguards to protect confidential information.

GOVERNING LAW

This form 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 conflict of law principles.

ENTIRE AGREEMENT

This document, together with any attachments or schedules expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior and contemporaneous understandings, agreements, representations and warranties, written or oral.

CERTIFICATION AND AUTHORIZATION

By signing below, the undersigned certifies under penalty of law that the information contained herein is true, complete and accurate, that the Applicant is authorized to provide such information, and that the Applicant will notify Verifier promptly in writing of any material change. The undersigned further authorizes Verifier to verify any information provided and to obtain such additional documentation as reasonably necessary to confirm the Applicant's business purpose and source of funds.

Applicant Authorizing Representative:

Title:

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