Fill and Sign the Initial Disclosure Statement Form

Retail Charge Account Agreement Initial Disclosure Statement New Account Date: ______________ Account No. ____________________ Seller's Name: _______________________ (Name of Seller) Seller's Business Address: ________________________________________________ ___________________________________________________ (Address of Seller) Buyer's Name: ________________________ (Name of Buyer) Buyer's Address: ________________________________________________________ ___________________________________________________ (Address of Buyer) In this agreement, the words you and your mean you as the customer. The words we, us, and our mean _______________________ (Name of Creditor) . 1. Purchases: Every purchase (including mail and phone orders) made by you and anyone else you authorize to use this account or the _______________________ (Name of Creditor) charge card under this agreement shall be recorded on one of our forms, and the amount of all purchases so made will be paid by you as stated in this agreement. If you place a mail or telephone order for a charge account purchase, we have the right to charge your account and to complete on your behalf a form recording that purchase. 2. Minimum Required Monthly Payments: You agree to pay, within _____ (number) days of receipt of a statement, to ________________________ (Name of Creditor) at ______________________________________________________________________ (street address, city, state, zip code) , the total amount of purchases made under this agreement, plus any applicable FINANCE CHARGES . The total amount owing at the close of any billing period (New Balance) may be paid in full prior to the closing date of the next following billing period, or may be paid in monthly installments in accordance with _____________________ (Name of Creditor) 's Charge Account payment terms generally in effect when the statement is mailed. The current Charge Account payment terms of _______________________ (Name of Creditor) are shown below. If you fail to make any payment when it is due, we may demand immediate payment of the full balance (including FINANCE CHARGES ). (Set forth charge account payment terms) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 3. During any monthly billing period, no finance charge will be imposed if you pay the full New Balance within _______ (number) days after the Closing Date as shown on the statement for that period. Otherwise, finance charges accrue from the date we post each new transaction to your account. 4. If you choose to pay less than the full New Balance, a FINANCE CHARGE will be included on your next monthly statement. We figure the FINANCE CHARGE on your account by applying the periodic rate to the adjusted balance of your account. We get the adjusted balance by taking the balance you owed at the end of the previous billing cycle and subtracting any unpaid finance charges and any payments and credits received during the present billing cycle. To avoid a FINANCE CHARGE, the total amount owing at the close of any billing period (New Balance) must be received by us prior to the closing date of the next following billing period. The maximum amount or rate of the monthly FINANCE CHARGE to be imposed under this agreement is as follows: a minimum $___________ FINANCE CHARGE may be imposed if the unpaid Previous Balance is less than $_________; any greater FINANCE CHARGE will be determined by applying a periodic rate of _________% corresponding ( ANNUAL PERCENTAGE RATE) to the first $____________ of the Previous Balance, and of _______% corresponding ( ANNUAL PERCENTAGE RATE) to any excess Previous Balance over $____________. 5. A Late Charge ($__________ minimum) and ($________ maximum) of _________ % of the late amount will be imposed on any past due amount when not paid by the applicable payment due date, and on any current due amount when not paid within ______ (number) days after the applicable payment due date. 6. Change of Terms: Subject to any applicable law, we may at any time change the terms of this account generally for all customers, including the payment schedule and FINANCE CHARGE, effective on mailing a notice of the change to you. Any change may affect amounts owed on the date the change is effective as well as amounts due for purchases made after the change. 7. The charge card to be furnished you by us remains our property and will be surrendered to us on demand. We reserve the right to decline further sales under this agreement at any time and this agreement may be terminated at any time by either of us, but such termination shall not affect your then existing obligations under this agreement. 8. YOU MAY PAY YOUR TOTAL BALANCE WITHOUT A PENALTY AT ANY TIME. 9. Reasonable attorney's fees and court costs (that is, required filing fees, etc.) may be requested to be awarded to ___________________ (Name of Creditor) in connection with any legal action to recover on default under this agreement. 10. Security Interest: __________________ (Name of Creditor) agrees that no security interest is or will be retained or acquired under this account. 11. You authorize us to investigate your credit-worthiness and to furnish information concerning your performance of this account to credit reporting agencies and others who may lawfully receive such information. 12. YOUR BILLING RIGHTS -- KEEP THIS NOTICE FOR FUTURE USE This notice contains important information about your rights and our responsibilities under the Fair Credit Billing Act. Notify Us in Case of Errors or Questions About Your Bill If you think your bill is wrong, or if you need more information about a transaction on your bill, write us on a separate sheet at _____________________________________ _______________________________________________ (street address, city, state, zip code) or the address listed on your bill . Write to us as soon as possible. We must hear from you no later than 60 days after we sent you the first bill on which the error or problem appeared. You may telephone us, but doing so will not preserve your rights. In your letter, give us the following information:  Your name and account number.  The dollar amount of the suspected error.  Describe the error and explain, if you can, why you believe there is an error. If you need more information, describe the item you are not sure about. If you authorized us to pay your credit card bill automatically from your savings or checking account, you can stop the payment on any amount you think is wrong. To stop the payment, your letter must reach us three business days before the automatic payment is scheduled to occur. Your Rights and Our Responsibilities After We Receive Your Written Notice We must acknowledge your letter within thirty (30) days, unless we have corrected the error by then. Within ninety (90) days we must either correct the error or explain why we believe the bill was correct. After we receive your letter, we cannot try to collect any amount you question or report you as delinquent. We can continue to bill you for the amount you question, including finance charges, and we can apply any unpaid amount against your credit limit. You do not have to pay any questioned amount which we are investigating, but you are still obligated to pay the parts of your bill that are not in question. If we find that we made a mistake on your bill, you will not have to pay any finance charges related to any questioned amount. If we didn't make a mistake, you may have to pay finance charges, and you will have to make up any missed payments on the questioned amount. In either case, we will send you a statement of the amount you owe and the date that it is due. If you fail to pay the amount that we think you owe, we may report you as delinquent. However, if our explanation does not satisfy you and you write to us within ten (10) days telling us that you still refuse to pay, we must tell anyone we report you to that you have a question about your bill. And, we must tell you the name of anyone we reported you to. We must tell anyone we report you to that the matter has been settled between us when it finally is. If we don't follow these rules, we can't collect the first $50 of the questioned amount, even if your bill was correct. Special Rules for Credit Card Purchases If you have a problem with the quality of property or services that you purchased with a credit card, and you have tried in good faith to correct the problem with the merchant, you may have the right not to pay the remaining amount due on the property or services. There are two limitations on this right: A. You must have made the purchase in your home state or, if not within your home state, within 100 miles of your current mailing address; and B. The purchase price must have been more than $50. These limitations do not apply if we own or operate the merchant, or if we mailed you the advertisement for the property or services. NOTICE TO BUYER DO NOT SIGN THIS AGREEMENT BEFORE YOU READ IT OR IF IT CONTAINS BLANK SPACES. YOU ARE ENTITLED TO A COPY OF THE AGREEMENT YOU SIGN. KEEP THIS AGREEMENT TO PROTECT YOUR LEGAL RIGHTS. I ACKNOWLEDGE RECEIPT OF A COPY OF THIS RETAIL CHARGE ACCOUNT AGREEMENT . _________________________ Date: _______________ (Printed Name of Customer) _________________________ (Signature of Customer)