Financial Wire Information Form

FINANCIAL WIRE INFORMATION FORM

WHEREAS, Remitter Name: (the "Remitter") desires to transmit funds by electronic wire transfer to the Payee identified herein; and

WHEREAS, Payee Name: (the "Payee") has provided account and routing information and has authorized receipt of such funds for the purpose set forth below; and

WHEREAS, the parties agree that Remitter will rely on the information provided in this form to initiate one or more electronic funds transfers under the terms and conditions set forth below.

Scope of Wire Instructions

Provide a detailed description of the payment purpose, permitted recipients, frequency, and any invoice or contract references. This description defines the intended scope of transfers and any limitations on the use of provided wire details.

Wire Recipient (Beneficiary) Banking Details

Payment Terms

Amount to be wired: Currency:

Late payment fee: (applies to overdue balances unless otherwise agreed in writing).

Term and Termination

This authorization is effective as of Start Date: and shall remain in force until End Date: unless earlier terminated in accordance with this section.

Either party may terminate this authorization upon written notice to the other party delivered not less than Notice Period (days): prior to the intended termination date. Termination does not affect obligations arising from transfers initiated prior to the effective date of termination.

Confidentiality

Each party shall hold in strict confidence all non-public banking, account and transaction information provided pursuant to this form, and shall not disclose such information except (a) to its bank, auditors, legal counsel or service providers on a need-to-know basis; (b) as required by law or a valid subpoena; or (c) with the prior written consent of the other party. Reasonable safeguards shall be used to prevent unauthorized disclosure.

Authorization, Certification and Indemnity

By providing the banking details and signing below, the Remitter certifies that the information is true, accurate and complete and authorizes the Remitter's bank to debit funds for the purpose described. The Payee certifies that it is the lawful beneficiary of the account identified. Each party agrees to indemnify and hold the other harmless from any loss, liability or expense arising from inaccurate information, forgery, fraudulent or unauthorized instructions, or failure to follow the controls specified herein, except to the extent caused by the gross negligence or willful misconduct of the indemnified party.

I certify that I am authorized to provide these bank details on behalf of the Beneficiary.
I certify that neither party nor the transaction is subject to applicable sanctions or export controls that would prohibit this transfer.
I have reviewed the banking details and accept responsibility for their accuracy.

Governing Law; Entire Agreement

This form and any dispute arising out of or relating to it shall be governed by the laws of the Jurisdiction: without regard to conflict of law principles. This form constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior or contemporaneous communications, representations, or agreements, whether oral or written.

Acknowledgment

The parties acknowledge that banks may impose fees for wire initiation, transmission, intermediary processing, and receipt. Each party is responsible for fees imposed by its own bank unless otherwise agreed in writing. The Remitter acknowledges that execution of a wire transfer is subject to banking cut-off times and potential delays outside the control of the parties.

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