Client Data Update Form

CLIENT DATA UPDATE FORM

WHEREAS

WHEREAS, Client Name: is a party to an existing business relationship with Service Provider Name: ; and

WHEREAS, the parties require written, auditable confirmation of any changes to the Client's account data to ensure accurate invoicing, delivery, compliance and communications; and

WHEREAS, the parties agree that updates will be processed in accordance with the terms set forth below and that the Service Provider may require verification documentation prior to effecting certain changes.

CLIENT IDENTIFICATION

SCOPE OF UPDATE

The Service Provider shall update Client account records to reflect the data changes submitted below. The scope of required processing includes validation of supplied documentation, modification of account fields, notification to affected internal departments, and amendment of billing or delivery instructions as necessary.

DATA ELEMENTS TO BE UPDATED

Select each element to be updated and provide the new value in the corresponding field.

SUPPORTING DOCUMENTATION

Indicate which documents are provided to substantiate the requested change. Service Provider may withhold processing until required documentation is received.

PAYMENT TERMS FOR PROCESSING FEES

If applicable, the Client agrees to reimburse the Service Provider for reasonable administrative fees charged for verification and processing of the requested updates. Payment terms are set out below.

TERM AND TERMINATION

The obligation to implement the updates described herein commences on the Effective Date below and continues until the update is completed and accepted by the Client or until terminated in accordance with the notice provisions below.

Effective Date: . Expected Completion Date: .

CONFIDENTIALITY

All personal, financial and account information disclosed by the Client in connection with this update shall be treated as confidential information. The Service Provider shall use such information solely for the purpose of processing the requested updates, shall limit access to authorized personnel, and shall not disclose such information to third parties except (a) as required to complete the update, (b) to comply with law or lawful process, or (c) with the Client's prior written consent. Reasonable administrative, technical and physical safeguards must be maintained to protect the confidentiality and integrity of the Client's data.

GOVERNING LAW

This form and any dispute arising out of or related to these data update procedures shall be governed by and construed in accordance with the laws of the jurisdiction in which the Service Provider maintains its principal place of business, without regard to conflict-of-law principles.

ENTIRE AGREEMENT

This Client Data Update Form, together with any referenced attachments, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous understandings, representations and agreements, whether written or oral. Any amendment or waiver must be executed in writing and signed by authorized representatives of both parties.

CERTIFICATION AND AUTHORIZATION

I certify under penalty of perjury that the information provided in this form is true and accurate to the best of my knowledge. I authorize the Service Provider to update its records in accordance with the instructions contained herein and to contact the listed authorized contacts for verification purposes. I acknowledge that false statements may result in rejection of the update request or other remedies.

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