Financial Revocation Statement

FINANCIAL REVOCATION STATEMENT

Client Name:    Recipient / Institution Name:

Account or Reference Number:    Original Authorization Date:

Statement of Revocation

I, the undersigned Client, hereby revoke, cancel and terminate any and all financial authorizations, mandates, powers of attorney, standing payment instructions, direct debit authorizations, and similar consents previously granted to the Recipient identified above with respect to the account or reference number listed in this statement. This revocation is effective as of (Effective Revocation Date).

The scope of this revocation includes, without limitation, the cessation of any authorization to: initiate electronic debits or credits; withdraw funds by automatic transfer, ACH, or wire; transfer funds by check or other negotiable instrument endorsed on my behalf; and to act under any financial power of attorney previously granted by me to the Recipient.

Scope and Limitations

This revocation applies only to future authorizations and instructions issued on or after the Effective Revocation Date. It shall not invalidate or reverse transactions that were authorized and irrevocable under applicable law or that were initiated prior to the Effective Revocation Date. The Recipient retains any rights to pursue settlement or recovery for transactions already processed in good faith prior to receipt of this Revocation Statement.

Types of Authorization Revoked (select all that apply)

Automatic debit / recurring payment ACH debit / credit transfer Wire transfer authorization

Power of attorney / third-party access Check endorsement / negotiated instrument authority Other (describe)

Actions Required of Recipient

Upon receipt of this Financial Revocation Statement, the Recipient shall:

1. Immediately cease all future debits, transfers, or other financial actions that rely upon the revoked authorization.
2. Provide written confirmation to the Client at the contact information below acknowledging receipt of this revocation and identifying the date when the Recipient ceased processing future transactions under the revoked authorization.
3. Preserve records demonstrating cessation of debits and any instructions given to third parties to stop processing under the revoked authorization.

Certification and Indemnity

I certify under penalty of perjury under the laws of the applicable jurisdiction that the information contained in this Financial Revocation Statement is true and correct to the best of my knowledge and that I have the full authority to revoke the authorization identified herein. I acknowledge that I remain responsible for any obligations or liabilities arising from transactions authorized and executed prior to receipt of this revocation. To the extent permitted by law, I agree to indemnify and hold harmless the Recipient and any financial institution acting in good faith from claims, losses or liabilities arising from actions taken prior to confirmation of cessation or arising from my failure to provide accurate information.

Attachments and Evidence

Evidence provided with this Revocation Statement (select all that apply):

Copy of government-issued ID Prior authorization document Other supporting documents

Acknowledgment of Receipt (for Recipient use)

The Recipient may complete the acknowledgment below to confirm receipt. Completion of the acknowledgment is optional and does not affect the effectiveness of the revocation; however, the Client requests confirmation to the contact information provided above.

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