Creditor Information Questionnaire

CREDITOR INFORMATION QUESTIONNAIRE

Parties and Recitals

Creditor Name:

Requesting Party Name:

WHEREAS, Creditor Name above is a person or entity that has extended credit, holds or services one or more accounts, and maintains records and documents relating to such accounts; and

WHEREAS, Requesting Party Name above requires a structured compilation of creditor information for account review, due diligence, collection, or other legitimate business purposes and Creditor is willing to provide the requested information subject to the terms and conditions set forth in this Questionnaire and Agreement;

NOW, THEREFORE, Creditor and Requesting Party agree that Creditor shall provide the information described below consistent with the representations, warranties and confidentiality obligations contained herein.

Creditor Contact and Account Information

Individual Corporation LLC Partnership Other

Scope of Information Requested

Payment Terms (applicable to services or fees)

Fee Amount:    Payment Schedule:

Late Payment Fee (if any):

Term and Termination

Term Commencement Date:    Term Expiration Date:

Either party may terminate this Questionnaire and the obligations hereunder upon written notice to the other party delivered at least days prior to the intended termination date. Termination shall not relieve either party of obligations that accrued prior to termination, including payment and confidentiality obligations.

Confidentiality

Creditor and Requesting Party acknowledge that information exchanged under this Questionnaire may include non-public, proprietary or personally identifiable information ("Confidential Information"). Each receiving party shall: (a) hold Confidential Information in strict confidence using at least the same degree of care that it uses for its own similar information but no less than reasonable care; (b) use Confidential Information solely to evaluate and perform obligations set forth in this Questionnaire; and (c) not disclose Confidential Information to any third party except to employees, agents or advisors who have a need to know and who are bound by confidentiality obligations no less protective than those herein. Confidential Information does not include information that is or becomes generally available to the public other than by breach of this Questionnaire, independently developed without use of the Confidential Information, or obtained from a third party having the lawful right to disclose it.

Representations and Warranties; Certifications

Creditor represents and warrants that, to the best of its knowledge, the information provided is true, complete, and accurate as of the date of signing. Creditor further certifies that it has the authority to disclose the information and that disclosure will not violate any agreement or law. Requesting Party represents that it will use the information only for legitimate business purposes and in accordance with applicable law.

Certification: I certify that the information provided in this Questionnaire is accurate and complete to the best of my knowledge and that I am authorized to make this certification.

Governing Law; Entire Agreement

Governing Law: This Questionnaire and any disputes arising out of or relating to it shall be governed by and construed in accordance with the laws of the state or jurisdiction specified below, without regard to conflict of laws principles.

Governing Jurisdiction:

Entire Agreement: This Questionnaire, including all attachments and 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, whether written or oral.

Additional Disclosures and Attachments

Most recent account statement Security agreement / UCC filings Promissory note or credit agreement Other (describe below)

Notices

All notices or other communications required or permitted under this Questionnaire shall be in writing and delivered to the addresses set forth in this Questionnaire or as otherwise designated in writing by the parties. Notice shall be effective upon receipt if delivered personally, by nationally recognized overnight courier, or three (3) business days after mailing by certified mail, return receipt requested.

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