Client Information Mismatch Form

CLIENT INFORMATION MISMATCH FORM

RECITALS

WHEREAS, Client Name: has submitted information that is materially inconsistent with information maintained in the Company's records; and

WHEREAS, the parties desire to identify the scope of discrepancy, establish corrective actions, and record any compensation or fees associated with correction of official records effective as of .

NOW, THEREFORE, the Client and the Company agree as set forth below.

REPORT DETAILS

Report Date:   Priority:

IDENTIFIED DISCREPANCIES

Provide up to three discrete mismatches below. Attach supporting documents where applicable.

Supporting documentation attached:

Supporting documentation attached:

Supporting documentation attached:

SCOPE OF DISCREPANCY & CORRECTION ACTIONS

PAYMENT TERMS

Correction Fee Amount:   Payment Schedule:

Late Fee:   Fee Waiver Conditions:

TERM AND TERMINATION

Correction Term Start:   Correction Term End:

Termination for Cause: Either party may terminate corrective actions upon written notice delivered to the other party. Notice Period (days):

CONFIDENTIALITY

All information submitted in connection with this form (including identity documents, account details and internal notes) constitutes Confidential Information. The receiving party shall use such information solely to verify and correct client records and shall not disclose such information except as required by law or with the prior written consent of the disclosing party. The receiving party shall apply administrative, technical, and physical safeguards no less protective than those used to protect its own confidential information.

I acknowledge the confidentiality obligations above:

SUPPORTING DOCUMENTS

Please indicate which documents are provided with this submission:

Proof of Identity (government ID)

Proof of Address (utility bill, bank statement)

Signed Authorization (if another party requested change)

GOVERNING LAW; ENTIRE AGREEMENT

This Form and any actions taken pursuant to it shall be governed by the laws of the jurisdiction identified as: , without regard to conflict of law principles. This document, together with any written approvals and attachments executed by the parties, constitutes the entire agreement between the parties with respect to the matters set forth herein and supersedes all prior representations and agreements relating to the same subject matter.

CERTIFICATION AND APPROVAL

By signing below, each signatory certifies that they are authorized to provide the information herein, that the information is true and correct to the best of their knowledge, and that they accept the terms and fees described above for the correction of client records.

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