Financial Bank Request Form

FINANCIAL BANK REQUEST FORM

Request Summary

Date of Request:    Request Reference #:

Purpose of Request:

Requestor Information

Individual    Corporation    LLC    Partnership    Trust    Other:

Bank & Account Information

Checking    Savings    Money Market    Other:

Requested Action

Please select the requested banking action(s) and provide required details below. Processing may be delayed if required information or supporting documentation is omitted.

Open new account    Close account    Add / Remove / Change signatory authority    Wire transfer    Stop payment    ACH origination / Direct debit setup    Statement copy / Account history    Other:

Wire Transfer Details (complete if requesting a wire)

Stop Payment / Check Details (if applicable)

Signatory / Authority Changes

Provide names, titles and scope of authority for any new or removed signatories. All corporate requests must be accompanied by a certified corporate resolution or equivalent evidence of authority.

Supporting Documentation

The following documentation is required as applicable; failure to provide required documentation may delay processing.

Government-issued photo ID    Corporate resolution / minutes    Signature card    Voided check / bank letter    Power of attorney

Fees, Processing & Representations

By submitting this request, the requester certifies that the information provided is true, complete and accurate to the best of the requester's knowledge. The requester represents that it is authorized to make this request on behalf of the named client and will provide any further documentation reasonably required by the bank to verify authority or identity.

The requester acknowledges that the bank may assess fees for processing the requested action, including but not limited to wire fees, stop-payment fees or research fees, and that fees may be deducted from the account specified. The bank is authorized to act on this instruction according to its standard policies and may refuse action where it reasonably suspects fraud, lack of authority, ambiguity in the instruction, or regulatory restriction.

The requester agrees to indemnify and hold the bank harmless from any losses, claims, liabilities, or expenses arising from reliance on the information and instructions provided, except where such losses result from the bank's gross negligence or willful misconduct. The bank's liability, if any, will be limited to direct damages and shall not include consequential or punitive damages.

Processing timelines are subject to the bank's operational hours and may vary by transaction type and jurisdiction. Requests received without required documentation or during periods of heightened review may require additional time for completion.

Internal Use — Bank Processing

Certification & Authorization

I hereby certify under penalty of perjury that I am authorized to execute this request on behalf of the client named herein and that all information submitted is true and correct. I authorize the bank to process the requested action(s) described in this form and to debit any applicable fees to the account indicated. I acknowledge that additional documentation may be required for certain actions and that submission of this form does not guarantee execution absent satisfactory verification and acceptance by the bank.

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