Change of Circumstance Form

Change of Circumstance Form

Client Name:

Company Name:

Recitals

WHEREAS, the parties entered into a binding agreement identified by Account/Reference Number: dated (the "Original Agreement");

WHEREAS, a material change of circumstance has occurred described as: which impacts performance, billing, or compliance under the Original Agreement;

WHEREAS, the parties desire to document the change and set adjusted terms by completing this Change of Circumstance Form and, where applicable, amending the Original Agreement as set forth below.

Scope of Change

Describe the changed circumstance and the specific adjustments requested or required. Include factual background, dates, and any immediate operational impacts.

Type of Change (select all that apply)

Address / Contact Information
Billing or Payment Terms
Ownership / Authorized Signatory
Bank Account / Payment Method
Tax or Regulatory Status
Other (describe below)

New/Updated Information

Effective Date of Change:

Payment Terms (if applicable)

Adjustment to fees or payments resulting from this change shall be as follows:

Late payment fee (if any):

Invoices related to adjustments will be issued in accordance with the agreed invoicing procedures. Any disputed charges must be submitted in writing within thirty (30) days of invoice receipt.

Term and Termination

Unless otherwise stated below, the change shall be effective on the Effective Date indicated above and shall continue until the end date specified or until terminated pursuant to the Original Agreement or this Form.

Termination for cause shall follow the notice and cure provisions of the Original Agreement. Termination for convenience shall require written notice as specified above, unless otherwise agreed in writing.

Confidentiality

All nonpublic information exchanged in connection with this Change of Circumstance Form shall be treated as Confidential Information under the confidentiality provisions of the Original Agreement. If no confidentiality provision exists in the Original Agreement, the parties agree that Confidential Information shall mean information designated in writing as confidential and that such information shall not be disclosed except (i) to fulfill obligations under this Form, (ii) as required by law, or (iii) with prior written consent of the disclosing party. Any permitted disclosure shall be limited to persons with a need to know and subject to confidentiality obligations at least as protective as those herein.

Governing Law

This Form shall be governed by and construed in accordance with the laws of the state of without regard to its conflicts of law principles.

Entire Agreement

This Change of Circumstance Form, together with the Original Agreement, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior discussions and understandings pertaining to such subject matter. Except as expressly modified by this Form, all terms and conditions of the Original Agreement remain in full force and effect.

Supporting Documentation

Attachments submitted with this Form (check all that apply):

Proof of address
Authorization letter for signatory changes
Bank account verification document
Tax documentation (if applicable)
Other (describe below)

Acknowledgment

By signing below, the undersigned certifies that the information provided in this Change of Circumstance Form is true, complete and accurate to the best of their knowledge, and that they are authorized to request the changes set forth herein. The undersigned authorizes the recipient to make any inquiries necessary to verify the information provided and acknowledges that false statements may result in corrective action under the Original Agreement or applicable law.

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