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Customer Disclosure Form

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CUSTOMER DISCLOSURE FORM

Customer and Company Identification

Recitals

WHEREAS, the Company named above provides products and/or services as described in the Scope of Work below and maintains practices for disclosure and handling of customer information;

WHEREAS, the Customer is entering into a contractual relationship with the Company and acknowledges that certain information must be disclosed to the Customer in accordance with applicable business practices and the terms set forth herein;

WHEREAS, the parties desire to set forth their respective obligations, disclosures and acknowledgements in writing to avoid misunderstandings and to protect confidential information and the parties' rights.

Scope of Work

Describe the goods or services to be provided under this disclosure. The description should identify deliverables, milestones, performance standards and any limitations on services:

Payment Terms

Total Amount Due: $

Late Payment Fee: . The Customer agrees that late payments will accrue interest or fees as stated and that the Company may suspend performance pending cure of any overdue amounts after notice.

Term and Termination

Term Commencement Date: . Term Expiration Date:

Either party may terminate this agreement for material breach that remains uncured for days after written notice. Upon termination, outstanding sums for services rendered through the effective termination date remain immediately due and payable.

Customer Disclosures

The Company discloses the following practices and authorizations. The Customer acknowledges receipt and understanding by checking the applicable boxes below.

I acknowledge the Company's privacy practices concerning collection and use of personal information necessary to provide services.

I acknowledge that the Company may share non-sensitive information with third-party service providers for performance of contracted services, subject to confidentiality obligations.

I acknowledge any applicable fees, billing practices, and the Company's policies for disputed charges as described in Payment Terms.

Confidentiality

Each party agrees that Confidential Information disclosed by the other party shall be held in strict confidence and used only for the purposes of performing obligations under this agreement. Confidential Information does not include information that is: (a) already known to the receiving party without obligation of confidentiality; (b) becomes publicly known through no wrongful act; (c) lawfully received from a third party without breach; or (d) independently developed without use of the disclosing party's Confidential Information.

Confidentiality Duration: Confidential obligations shall continue for years following the termination or expiration of this Agreement.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to its conflict of laws principles. The parties submit to the exclusive jurisdiction of the state and federal courts located in that State for resolution of disputes arising from this Agreement.

Acknowledgements and Entire Agreement

The Customer acknowledges receipt of all disclosures required by the Company and confirms that all information provided to the Company is true and accurate to the best of the Customer's knowledge. The Customer authorizes the Company to act in reliance on such information.

Entire Agreement: This document, including any attachments and mutually executed statements of work, constitutes the full and complete agreement between the parties concerning the subject matter hereof and supersedes all prior oral or written agreements, representations, or understandings. No amendment shall be effective unless in writing and signed by authorized representatives of both parties.

Customer Certification

By signing below, the Customer certifies that they have read and understood this Customer Disclosure Form, the Scope of Work, Payment Terms, and Confidentiality terms, and consent to the disclosures described herein. The Customer further confirms that they have authority to bind the Customer entity identified above.

Customer Printed Name:

Date of Acknowledgement:

Customer:

By:

Date:

Company:

By:

Date:

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What the Customer Disclosure Form Is and when it's used

A Customer Disclosure Form is a written statement provided to a customer that explains material terms, risks, fees, data uses, or legal rights tied to a product or service. It typically identifies the parties, describes what is being disclosed, lists financial or privacy-related terms, and includes a signature block for customer acknowledgment. Organizations use this document to satisfy statutory or contractual disclosure obligations, create an auditable record of consent, and reduce downstream disputes by making key information clear before performance or payment occurs.

Why a clear Customer Disclosure Form matters

A concise, accurate disclosure reduces legal risk, documents consent under ESIGN/UETA, and supports regulatory compliance for consumer financial and healthcare interactions.

Why a clear Customer Disclosure Form matters

Typical users and signers of the Customer Disclosure Form

Organizations that handle consumer transactions or regulated information commonly prepare and distribute these forms to meet disclosure obligations.

  • Real estate brokers and property managers who must disclose material property facts and fees to tenants or buyers.
  • Healthcare providers and clinics collecting consent and HIPAA-related disclosures for treatment and data sharing.
  • Banks, lenders, and fintech firms disclosing fees, terms, and privacy practices to account holders.

The form should be routed to the responsible business unit and retained according to applicable recordkeeping rules once signed.

Step-by-step: complete and obtain a valid disclosure signature

Follow these sequential actions to prepare, present, and archive the completed Customer Disclosure Form.

  • 01
    Prepare the form: Populate party names, effective date, and clear disclosure language.
  • 02
    Verify identity: Confirm signer identity using acceptable ID or electronic authentication.
  • 03
    Present disclosure: Provide the full form and any consumer-rights disclosures required by law.
  • 04
    Capture signature: Obtain signer intent and retention evidence before closing the record.

Typical electronic workflow for issuing the Customer Disclosure Form

A standard eSubmission workflow reduces friction and records every action, from upload to final storage.

  • Upload document: Add a PDF or DOCX version of the disclosure to the signing platform.
  • Place fields: Insert signature, date, and required data fields for each signer.
  • Choose authentication: Select email, SMS code, or stronger methods as appropriate.
  • Send and record: Deliver link or email, capture actions, and store the audit trail.

Configuring an online disclosure workflow

Set these workflow elements before sending to ensure enforceability and correct routing.

Field Configuration
Authentication Email link, SMS code, or KBA where required
Conditional Fields Show or hide sections based on prior answers
Retention Automated archive with exportable audit trail
Notifications Email alerts for signers and internal approvers

Electronic signature versus cryptographic digital signature

Understand the distinction so you can choose a signing method that satisfies legal and industry technical requirements.

Criteria Electronic Signature Digital Signature
Definition any electronic process pki-based certificate
Legal status recognized under esign/ueta recognized; stronger non-repudiation
Typical use consumer agreements high-assurance regulated records
Auditability audit trail evidence cryptographic verification

eSignature provider comparison for executing Customer Disclosure Forms

Basic pricing and feature differences among common eSignature vendors; signNow is listed first per comparative layout rules.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varied Varied Varied Varied
Bulk Send Yes (Business Premium) Yes Yes Yes Yes
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Essential information typically required on the form

Customer Name: Full legal name
Contact Address: Street, city, state, ZIP
Tax Identifier: SSN or TIN
Effective Date: MM/DD/YYYY format
Disclosure Details: Material terms and fees
Signature: Signer name, date

Key risks and penalties for incorrect or missing disclosures

Incorrect 1099: Penalties under IRC §6721
Late 1099: $60–$330 per form
Intentional disregard: $660+ per form
I-9 violations: $281–$2,789 per violation
HIPAA breach: Civil penalties and corrective action
Identity mismatch: Possible rejection and withholding

Common timing rules affecting disclosure-related reporting

Certain tax and reporting deadlines intersect with disclosure and information forms; plan execution and delivery accordingly.

W-9:

Provide on payer request; no set filing deadline

W-2 to employee:

Jan 31 delivery to employee

1099-NEC:

Jan 31 to recipient and IRS

1099-MISC paper:

Feb 28 to IRS if paper filed

1099-MISC electronic:

Mar 31 to IRS if filed electronically

Key milestones from preparation to archive

A concise milestone sequence helps teams track progress from form drafting through final retention.

01

Draft and Review

Legal and compliance review of disclosure content before release.

02

Present to Customer

Deliver full disclosure and required consumer notices for consent.

03

Obtain Signature

Capture signer intent and authentication evidence; complete audit trail.

04

Archive and Retain

Store completed form and audit log per retention policy.

Practical tips for accurate, defensible Customer Disclosure Forms

Adopt consistent templates and verification steps to reduce errors and support legal compliance.

Use a standard template
Maintain a controlled template that includes required disclosures, signature blocks, and versioning to avoid ad hoc language.
Verify signer identity
Match name to ID, use SMS or KBA for higher-risk transactions, and document the authentication method in the audit trail.
Record consent evidence
Capture timestamps, IP addresses, and a copy of the final document to show intent and retention under ESIGN/UETA.
Review state-specific rules
Confirm notarization, witness, and retention requirements for the governing state before execution or recording.

Real-world examples of Customer Disclosure Form usage

These concise cases show how organizations apply disclosure forms in different contexts.

Optica Ventures (Real Estate)

Optica used a standardized disclosure for rental applications to document fees and lead disclosures.

  • The form was integrated into their application flow for faster review.
  • The change reduced follow-up questions and created a clear signed record for tenant files that simplified audits and tenant onboarding.

Fertility Centers of Illinois (Healthcare)

The clinic digitized patient disclosure and consent forms to include HIPAA authorizations.

  • Electronic signatures captured consent and data-sharing choices.
  • This preserved a complete audit trail, aligned with HIPAA retention requirements, and improved patient throughput without in-person paperwork.

Frequently asked questions about Customer Disclosure Forms

Answers to common execution, enforceability, and retention questions for teams preparing or accepting customer disclosures.


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