Financial Withholding Account Application

FINANCIAL WITHHOLDING ACCOUNT APPLICATION

Use this application to request establishment of a Financial Withholding Account ("Account") for the purpose of withholding, segregating and remitting funds as required by law or contractual obligation. Completion of this application does not constitute approval. The applicant certifies all information provided is true, accurate and complete.

APPLICANT IDENTIFICATION

CONTACT & MAILING

ACCOUNT DETAILS

FUNDING / BANK INFORMATION

Provide primary depository for movement of withheld funds. Submitted bank account information will be used for electronic debits/credits unless alternate wiring instructions are supplied and accepted in writing.

AUTHORIZATION, CERTIFICATION & TERMS

By signing below, Applicant certifies and authorizes as follows:

1. Applicant is duly authorized under its organizational documents and applicable law to open and maintain the requested Account and to enter into this agreement.
2. Applicant will use funds deposited in the Account solely for the withholding purpose identified in this application and shall comply with all applicable federal, state and local laws and regulations governing withholding, remittance and reporting.
3. Applicant authorizes the Account provider to initiate debit and credit entries to the bank account identified for funding. Applicant will provide any documentation reasonably requested to verify bank authority or identity.
4. Applicant acknowledges that the Account provider may assess fees, hold funds subject to hold periods, and suspend or terminate the Account if required by law, court order, or upon reasonable suspicion of fraud or material breach.
5. Applicant agrees to indemnify and hold harmless the Account provider from and against any losses, liabilities, costs or expenses arising from misstatement of facts in this application, misuse of withheld funds, or failure to comply with applicable withholding obligations.

Applicant further authorizes the Account provider to obtain and verify information about Applicant's identity, tax status and creditworthiness as necessary to process this application and to comply with legal obligations. Applicant consents to disclosure of Account information to governmental authorities, auditors, auditors' designees, payment networks, and other parties when required or permitted by law.

REQUIRED ATTACHMENTS

Attachments may be required to verify identity and authority: corporate formation documents, government-issued photo identification for individual signatories, tax exemption certificates, and bank account verification (voided check or bank letter). The Account provider may request originals or certified copies.

ACKNOWLEDGMENT AND SIGNATURE

The undersigned represents and warrants that the signatory is authorized to execute and deliver this application on behalf of Applicant and that the information contained herein is true and complete. Applicant agrees that execution may be evidenced by electronic signature and that such electronic signature shall be effective to bind Applicant.

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