Financial Signature Packet

FINANCIAL SIGNATURE PACKET

Client Name:    Packet Effective Date:

ENTITY INFORMATION

Corporation    LLC    Partnership    Sole Proprietor    Other:

PAYMENT METHOD AUTHORIZATION

The undersigned authorizes the payer to initiate payment by the selected method(s) and certifies that the information supplied below is accurate and complete. Select authorized payment methods:

ACH (Electronic Funds Transfer)    Wire Transfer    Check    Credit Card

BANKING DETAILS (COMPLETE FOR ACH OR WIRE)

Checking    Savings    Account Name:

INVOICING AND PAYMENT TERMS

Preferred Payment Terms:    Invoice Delivery Method: Electronic Hard Copy

SUPPORTING DOCUMENTS

Please indicate which documents are attached to this packet (attach originals or certified copies as required):

Tax certificate or tax form    Bank verification letter    Invoice sample    Additional authorization

CERTIFICATIONS, REPRESENTATIONS, AND AUTHORIZATION

The undersigned certifies and represents that: (a) the information provided in this Financial Signature Packet is true, complete and correct to the best of the signatory's knowledge; (b) the signatory is authorized to execute this Packet and to bind the entity identified above to the authorizations and certifications contained herein; (c) the payer and its agents may rely upon the authorizations contained in this Packet until receipt of written notice of revocation; and (d) the entity will indemnify and hold harmless the payer and its agents for any loss, claim or liability resulting from inaccurate information provided or from unauthorized instructions originating from the entity.

Authorization to Debit/Credit: Where ACH or wire authorization is selected, the undersigned authorizes the payer to debit or credit the designated bank account for payments, adjustments, refunds and chargebacks in accordance with the terms of this Packet and applicable law. This authorization is a continuing authorization until revoked in writing and the payer has had a reasonable opportunity to act on such revocation.

Privacy and Security: The entity consents to the collection and use of the information provided for payment processing and recordkeeping. The payer will maintain commercially reasonable safeguards to protect sensitive information; however the entity acknowledges that transmissions by electronic means carry inherent risks and agrees to hold the payer harmless for unavoidable disclosures arising from such transmissions, except to the extent resulting from the payer's gross negligence or willful misconduct.

ACKNOWLEDGMENTS

By signing below, the signatory affirms that he or she is an authorized representative of the entity identified above and has authority to execute this Financial Signature Packet on behalf of the entity. False statements made knowingly may be subject to civil and criminal penalties.

FINANCE DEPARTMENT USE ONLY

Verification completed by:    Date verified:

Approval: Approved    Not Approved    Notes:

Sign Now