Financial T183Corp Form

FINANCIAL T183CORP FORM

Purpose: This Financial T183Corp Form documents corporate authorization, financial statement submission, and consent to disclosure required for financial review and transaction processing. Completion and signature by an authorized corporate representative constitute certification of the accuracy of the information provided and authorization for the actions described herein.

Company Information

Fiscal Year End:

Entity Classification

Corporation Subsidiary Foreign corporation Other:

Authorization Purpose and Scope

Scope: The authorized representative identified herein may (a) submit financial statements and supporting documents on behalf of the company; (b) authorize release of such documents to financial institutions, auditors, designated payors, or their agents for purposes of credit evaluation, transaction completion, or compliance review; and (c) execute acknowledgments and verifications required to process the authorization.

Financial Statements Checklist

Please indicate which documents are attached or will be delivered in connection with this authorization:

Balance Sheet Income Statement Statement of Cash Flows Notes to Financial Statements Audit or Review Report (if applicable)

Report Prepared By:    Report Date:

Bank Account Authorization

Account Type: Checking Savings Other

Attachments: Voided check or bank letter attached

Declarations and Certifications

By signing this form the authorized representative certifies, under penalty of perjury or equivalent legal sanction applicable in the governing jurisdiction, that:

1. All information and documents provided to the recipient are true, complete and correct to the best of the signatory's knowledge and belief. The corporation shall promptly notify the recipient in writing of any material change to such information.

2. The signatory is an authorized officer, director, or agent of the corporation with authority to bind the corporation with respect to the matters set forth in this Form, including the execution of certifications and consents.

3. The corporation authorizes the recipient and its agents to verify, obtain, and exchange information (including credit, banking, and financial records) reasonably necessary to process transactions or complete the review described in this Form.

4. The corporation agrees to indemnify and hold harmless the recipient, its officers, and agents from any claims, liabilities, losses or expenses arising from false statements, omissions, or unauthorized disclosures resulting from inaccurate information provided by the corporation, except where such loss is caused by the recipient's willful misconduct.

5. This authorization shall remain in effect until revoked in a signed writing delivered to the recipient. Revocation does not affect actions taken in reliance on this authorization prior to receipt of the revocation.

Governing Law and Dispute Resolution: The parties agree that any dispute arising from this Form will be governed by the law of the jurisdiction indicated below and subject to the exclusive jurisdiction of the courts of that jurisdiction, except where binding arbitration is separately agreed in writing.

Governing Jurisdiction:

Consent to Electronic Communication

The corporation consents to receive communications, notices, and disclosures related to this authorization in electronic form at the contact details provided above. Consent to electronic communications may be withdrawn by written notice subject to reasonable processing time.

Internal Use / Processing

Certification and Signature

I hereby certify that I am an authorized representative of the corporation identified above, that I have read and understand the declarations and authorizations contained herein, and that the information provided on this Form and accompanying documentation is true, complete and correct.

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