Legal Payment Authorization Form

LEGAL PAYMENT AUTHORIZATION FORM

This Payment Authorization Agreement is entered into effective as of by and between Client Name: with primary address ("Client"), and Payee Name: with primary address ("Payee").

RECITALS

WHEREAS, Client desires to authorize Payee to initiate electronic debits or other lawful payment debits from Client's designated account for payments described in this Agreement; and

WHEREAS, Payee is willing to accept such payment authorizations and to rely upon the authorization for debits and to provide receipts and records in accordance with applicable banking and payment system rules; and

WHEREAS, the parties wish to set forth the terms, duration, and conditions under which such payments shall be authorized and effected.

NOW, THEREFORE

In consideration of the mutual covenants set forth herein, the parties agree as follows:

1. AUTHORIZATION

Client hereby authorizes Payee and Payee's agents to initiate debit entries to the account designated below and, if necessary, credit entries to correct any erroneous debits. This authorization shall apply to the account identified in Section 3 and shall remain in full force and effect until revoked in writing as provided in Section 4.

2. PAYMENT DETAILS

Payment Amount: $   Frequency: One-time Recurring   If recurring, interval:

Payment Start Date:   Payment End Date (if applicable):   Purpose/Invoice Reference:

3. PAYMENT METHOD

Selected method: ACH / Bank Transfer Check Card

4. TERM, REVOCATION AND TERMINATION

This Authorization shall commence on the Payment Start Date and continue until the earlier of (a) the Payment End Date, (b) full payment of all amounts due under the referenced invoice(s), or (c) revocation by Client in accordance with this Section. Client may revoke this authorization by providing written notice to Payee at least ten (10) business days prior to the next scheduled debit. Revocation will not affect debits initiated prior to Payee's receipt of revocation.

5. REPRESENTATIONS AND WARRANTIES

Each party represents and warrants that it has full authority to enter into this Agreement and to perform its obligations. Client represents that the account information provided is accurate and that Client is an authorized signer on the designated account. Payee represents that it will comply with applicable payment system rules and will provide receipts or written confirmation of debits upon Client request.

6. CANCELLATION, ERRORS, AND DISPUTES

If Client believes a debit was made in error, Client shall notify Payee in writing within thirty (30) days of the debit date describing the dispute with reasonable detail. Payee will investigate and, if warranted, promptly refund or correct any erroneous debits. Neither party will be liable for interest or penalties resulting from good-faith reliance on the other party's information.

7. CONFIDENTIALITY

The parties shall treat account information and transaction details as Confidential Information and shall not disclose such information except to the extent necessary to process payments, comply with applicable law, or as required by a financial institution. Confidentiality obligations shall survive termination of this Agreement for a period of three (3) years.

8. INDEMNIFICATION

Each party shall indemnify, defend and hold harmless the other party and its officers, directors and agents from and against any losses, claims, damages, liabilities, and expenses (including reasonable attorneys' fees) arising out of a breach of this Agreement, fraud, willful misconduct, or negligent provision of inaccurate payment instructions by the indemnifying party.

9. NOTICES

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below or to such other address as a party may designate by notice. Notice is effective upon delivery when delivered in person, by certified mail, or by overnight courier.

10. GOVERNING LAW; VENUE

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to its conflicts of law principles. The parties submit to the exclusive jurisdiction of the state and federal courts located in that State for any dispute arising out of this Agreement.

11. ENTIRE AGREEMENT; SEVERABILITY; AMENDMENT

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings. If any provision is held invalid or unenforceable, the remaining provisions shall continue in full force and effect. This Agreement may be amended only by a written instrument signed by both parties.

12. WAIVER; COUNTERPARTS

No failure or delay by either party to exercise any right shall operate as a waiver thereof. This Agreement may be executed in counterparts, each of which when executed shall be deemed an original and all of which together shall constitute one instrument.

13. ADDITIONAL INFORMATION

CERTIFICATION

By signing below, Client certifies that the information provided is true and correct, that Client is authorized to approve debits from the named account, and that Client authorizes Payee to initiate debits in accordance with this Agreement. Payee certifies that it will process debits only as authorized and will maintain appropriate records of transactions.

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