Financial Excess Funds Letter

FINANCIAL EXCESS FUNDS LETTER

Claimant Name:

WHEREAS

WHEREAS, ("Custodian") is in possession of funds identified as excess or overage arising from the account referenced as Account No. ; and

WHEREAS, Claimant asserts a right to all or part of the excess funds in the amount of $ and provides the representations, documentation, and authorizations set forth in this letter; and

WHEREAS, Custodian requires written instruction and sufficient documentation before disbursing such funds to Claimant or Claimant's designated payee in accordance with applicable law and the terms agreed herein.

SCOPE OF WORK

PAYMENT TERMS

Distributable Excess Amount: $. Claimant requests disbursement of $ in accordance with the schedule below.

Administrative Fee or Commission (if applicable): . Late payment interest: calculated from the date payment was due until paid.

TERM AND TERMINATION

This Letter is effective as of Start Date: and shall continue until End Date: , unless earlier terminated in accordance with this section.

Either party may terminate with written notice delivered at least days prior to the intended termination date. Termination shall not relieve Claimant or Custodian of obligations accrued prior to termination, including the obligation to pay fees or return funds improperly disbursed.

CONFIDENTIALITY

Each party shall maintain in confidence all non-public information disclosed in connection with this Letter, including financial information and personal identifiers ("Confidential Information"), and shall not disclose such information except to its employees, agents, counsel, or accountants who have a need to know and who are bound by confidentiality obligations at least as protective as those set forth herein. Confidential Information does not include information that is or becomes publicly available other than through a breach of this provision.

SUPPORTING DOCUMENTATION

Claimant submits the following documents to establish entitlement and to facilitate disbursement (check all that apply):

Identification (government-issued photo ID)    Proof of Address    Proof of Benefit/Ownership    Court Order or Judgment

REPRESENTATIONS, WARRANTY AND INDEMNITY

Claimant represents and warrants that Claimant is the lawful owner or an authorized representative entitled to receive the claimed funds and that all information and documentation provided to Custodian is true, complete and accurate. Claimant agrees to indemnify and hold harmless Custodian from and against any loss, liability, claim, cost or expense (including reasonable attorneys' fees) arising from any misrepresentation by Claimant or from disbursing funds in accordance with the instructions provided herein.

Claimant hereby checks to acknowledge these representations:

PAYMENT INSTRUCTIONS (IF DIRECT DEPOSIT)

GOVERNING LAW; ENTIRE AGREEMENT

This Letter shall be governed by and construed in accordance with the laws of the State of without regard to conflict of laws principles. This Letter constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior negotiations, representations, and agreements, whether written or oral.

MISCELLANEOUS

Notices under this Letter shall be in writing and delivered to the addresses provided above or to such other address as a party may designate in writing. If any provision of this Letter is found invalid or unenforceable, the remaining provisions shall remain in full force and effect.

ADDITIONAL INFORMATION

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