Financial Consent Forms

FINANCIAL CONSENT FORM

Parties and Purpose

Client Name:

Financial Institution / Payee Name:

Authorization

By signing this Financial Consent Form, Client authorizes the Payee to: initiate ACH debits or credits to the account specified below; initiate wire transfers where expressly selected; charge the designated credit or debit card where expressly selected; and to obtain and share relevant financial information strictly as authorized in this document. This authorization survives delivery by electronic transmission and remains in effect until revoked in writing as provided below.

Scope of Consent

Select the types of authorizations granted (check all that apply):

ACH debit/credit authorization
Wire transfer authorization
Credit/debit card charge authorization
Limited disclosure of financial records to third parties for transaction processing

Effective Date:    Termination Date (if applicable):

Representations, Warranties and Covenants

Client represents and warrants that the bank account information provided is accurate and that Client is authorized to permit debits and credits to that account. Client covenants to maintain sufficient funds to cover authorized debits. Client agrees to promptly notify Payee of any change in account ownership, account number, or other information affecting this authorization.

Fees, Liability and Indemnity

Client agrees to pay any fees assessed by financial institutions for returned items, insufficient funds, or wire handling as disclosed by Payee. Except for gross negligence or willful misconduct, Payee shall not be liable for consequential damages arising from processing of authorized transactions. Client shall indemnify and hold harmless Payee from claims, losses, or liabilities resulting from Client's breach of representations or unauthorized instructions issued by Client.

Revocation, Cancellation and Notices

This authorization may be revoked by Client by providing written notice to Payee no fewer than 30 days prior to the date the revocation is to be effective, except where law provides otherwise. Notice must be sent to the Payee contact information above. Payee may terminate or suspend this authorization upon reasonable notice if Client breaches any material obligation under this Form.

Data Privacy and Disclosure

Client consents to the collection, use and disclosure of Client's financial information solely to the extent necessary to effectuate authorized transactions, to comply with applicable laws, or to prevent fraud. Payee will use commercially reasonable safeguards to protect Client information. Client acknowledges that disclosures required by law may be made without further consent.

Dispute Resolution and Governing Law

Any dispute arising under this Financial Consent Form shall be governed by and construed in accordance with the laws of the state of: . Parties agree that venue for any litigation shall be in the state or federal courts located in that state, unless otherwise mutually agreed in writing.

Additional Instructions or Limits

Certification and Acknowledgment

By signing below, Client certifies under penalty of perjury that the information provided is true and correct, that Client has the full authority to grant the authorizations set forth herein, and that Client has read and understands the terms of this Financial Consent Form.

Electronic Signature Consent: Client consents to execute this document electronically and agrees that an electronic signature has the same force and effect as an original ink signature.

Sign Now