Business Receipts and Removals Form

BUSINESS RECEIPTS AND REMOVALS FORM

Business Name:

Business Address:

Authorized Representative:   Phone:

Recipient/Agent Name:   Organization:

RECITALS

WHEREAS, Business Name: is the owner, lessee, or authorized custodian of certain tangible goods, inventory, equipment, or records located at Business Address: ; and

WHEREAS, Recipient/Agent Name: has requested authority to remove specified items from the premises and Business has agreed to permit removal under the terms and conditions set forth in this form; and

WHEREAS, the parties intend to record the details of the materials removed, specify chain of custody and condition at removal, allocate liability, and set payment and return obligations where applicable.

SCOPE OF WORK / REMOVAL INSTRUCTIONS

RECEIPT & ITEMIZATION

Date of Removal:   Location of Removal:

Complete the table below for each item removed. Quantities and condition recorded at time of removal are binding unless a written discrepancy is submitted within 5 business days.

PAYMENT TERMS

Where removal services or disposition services are payable, the parties agree to the following:

Late Payment: A late fee of per month or the maximum permitted by law, whichever is less, will apply to past-due balances. Costs of collection, including reasonable attorneys' fees, are recoverable by the non-defaulting party.

TERM & TERMINATION

Effective Date:   Termination Date:

Either party may terminate this agreement for convenience upon days' prior written notice. Termination for cause is permitted immediately upon material breach that is not cured within 10 business days after written notice.

CONFIDENTIALITY

Each party shall treat as confidential all non-public information disclosed in connection with removals, including inventory lists, condition reports, pricing and business operations, and shall not disclose such information except as required by law or with the prior written consent of the disclosing party. Confidentiality obligations survive termination for a period of three (3) years.

LIABILITY, INDEMNITY & RISK ALLOCATION

Recipient acknowledges receipt of the items listed above and accepts responsibility for maintaining adequate insurance coverage once items leave Business premises, unless otherwise agreed in writing. Recipient shall indemnify and hold Business harmless from claims arising out of Recipient's negligence, willful misconduct, or breach of this form. Business retains liability for loss or damage to items prior to transfer of custody as evidenced by signatures below.

ACKNOWLEDGMENTS

By checking the boxes below, the signatory certifies the statements are true and accurate to the best of their knowledge and that they are authorized to execute this form on behalf of their organization.

Business confirms removed items are owned by or authorized for removal by Business and not subject to third-party liens except as disclosed.

Recipient confirms required insurance and licensing are in effect for transport, storage, or disposal of removed items.

GOVERNING LAW & ENTIRE AGREEMENT

This form is governed by the laws of the State indicated below. Any dispute arising under this form shall be resolved in the state or federal courts located in that state. This form, together with any attachments executed contemporaneously, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior negotiations and understandings.

NOTICES

All notices under this form must be in writing and delivered to the addresses listed above by hand, certified mail (return receipt requested), or nationally recognized courier service and are effective upon receipt.

Sign Now