Finance Rebate Renewal Form

Finance Rebate Renewal Form

Use this form to request renewal of an existing rebate arrangement. Complete all sections, attach required supporting documentation, and certify the representations below. Incomplete submissions may delay processing.

Applicant Information

Corporation LLC Sole Proprietor Partnership Other

Original Rebate Agreement Date:

Rebate Renewal Details

Renewal Term Start Date:    End Date:

Lump Sum Annual Quarterly Monthly

ACH Check Credit / Card

If ACH selected, provide account details below. By providing account details you authorize debit/credit entries consistent with payment schedule.

Supporting Documentation

Check each document included with this renewal request:

Proof of continued eligibility as required under original agreement

Sales reports or transaction summaries for the prior period

Tax identification documentation

Copy of original rebate agreement

Financial statements (if requested)

Eligibility Certification

The undersigned certifies, represents and warrants that all information contained in this renewal form and in any supporting documentation is true, complete and accurate. Applicant certifies continued compliance with all material eligibility requirements of the original rebate agreement, and agrees to notify the issuer immediately of any change that adversely affects eligibility.

Applicant acknowledges that the issuer retains the right to audit relevant records, require repayment of erroneous or improperly claimed rebate amounts, and to suspend or terminate rebate payments upon discovery of material misrepresentation or noncompliance. Applicant agrees to retain records relevant to rebate calculations for a minimum of five years and to provide access for audit upon reasonable request.

By checking the box below and signing, Applicant authorizes verification of the information provided and consents to any necessary information exchanges with third parties for the purpose of processing this renewal request.

I certify the foregoing and authorize verification as described above

Terms and Conditions (Key Provisions)

1. Renewal Effect: Upon acceptance by the issuer, this renewal extends the existing rebate agreement only to the extent expressly stated in the acceptance notice. All other terms of the original agreement remain in full force unless specifically modified herein.

2. Payment and Offsets: Rebate payments are subject to issuer approval and available budget. Issuer may offset any amounts owed by Applicant to issuer against rebate payments, including late fees or other charges arising under the rebate program.

3. Audit and Records: Applicant shall maintain accurate records supporting rebate claims. Issuer may audit claims and supporting documents. If an audit determines an overpayment, Applicant will promptly repay the overpaid amount plus interest at the lesser of the contract rate or statutory maximum, and reimburse reasonable costs of recovery.

4. Suspension and Termination: Issuer may suspend payments or terminate renewal if Applicant materially breaches the agreement or is subject to regulatory action that affects eligibility. Termination does not waive issuer's right to recover previously paid amounts.

5. Governing Law and Notices: This renewal shall be governed by the substantive law applicable under the original agreement. Notices shall be sent to the contact information provided on this form and shall be effective upon receipt.

Authorization and Consent

Applicant hereby authorizes issuer and its authorized agents to verify any information provided in this form and to obtain records necessary to determine continuing eligibility. Applicant consents to electronic processing of payments and to provide such documentation as issuer may reasonably request to effect payment.

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