Financial Bank Info Form

FINANCIAL BANK INFO FORM

Use this form to provide bank account details and authorize electronic fund transfers. Complete all applicable sections and supply supporting documentation as requested. Incomplete submissions may delay processing.

Account Holder / Company Information

Bank Account Information

Payment Authorization and Instructions

Select permitted transaction types. By selecting an option and signing below, the Account Holder authorizes the company listed above to initiate transfers as indicated and to debit or credit the account described above in accordance with the terms below.

Verification & Documentation

Provide one or more of the following to verify account ownership. Check all items provided. Originals or bank-issued documentation may be required for corporate accounts.

Legal Authorization, Certification and Liability

By signing below, the Account Holder certifies that the information provided on this form is true and correct and that the signatory is authorized to execute this authorization on behalf of the Account Holder. The Account Holder authorizes the Requesting Company to initiate Automated Clearing House (ACH) transfers, wire transfers and related adjustments as indicated above. This authorization remains in effect until the Requesting Company receives written notice of revocation signed by an authorized representative and has had a reasonable opportunity to act upon it.

The Account Holder agrees to indemnify and hold harmless the Requesting Company from any losses, claims, damages, liabilities, costs or expenses (including reasonable attorneys' fees) arising from errors in the information provided, failure to notify the Requesting Company of changes to account information, or unauthorized access to account credentials. The Requesting Company will not be liable for delays or failure to complete transfers due to incorrect information supplied by the Account Holder or due to circumstances beyond its control.

The Account Holder understands that bank cutoff times, clearing cycles and banking network rules apply. Any fees charged by financial institutions for returned items, rejected wires, or corrections are the responsibility of the Account Holder unless otherwise agreed in writing.

Additional Terms

Changes to account information must be submitted in writing and signed by an authorized representative. The Requesting Company reserves the right to require additional verification, including but not limited to in-person verification, notarized documents, or bank confirmation calls, prior to effecting changes or executing transfers.

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