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Legal PSP Disclosure Form

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Legal PSP Disclosure Form

This Legal PSP Disclosure Form (the "Disclosure") is entered into as of Date: by and between Payment Service Provider Name: with principal place of business at ("PSP"), and Client Name: with principal place of business at ("Client"). The PSP and Client are each a "Party" and together the "Parties."

RECITALS

WHEREAS, PSP provides payment processing, settlement, and related payment facilitation services, including merchant acquiring, routing, and reporting (the "Services"); and

WHEREAS, Client desires to engage PSP to provide the Services and requires written disclosure of PSP's material practices, third-party relationships, fees, data processing activities, and risk management procedures to permit Client to evaluate regulatory, compliance, and operational risks; and

WHEREAS, the Parties intend for this Disclosure to set forth the PSP's material disclosures and the Parties' respective acknowledgements in connection with the Services.

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows:

1. DEFINITIONS

Capitalized terms used in this Disclosure shall have the meanings set forth in the operative Services Agreement between the Parties. For purposes of this Disclosure, "Disclosed Fees" means all fees, charges, reserve requirements, and other amounts that PSP will assess directly or through third parties in connection with the Services.

2. SERVICES

PSP shall provide the Services described below. The Parties acknowledge that the scope of Services and any functional limitations will be set forth in the Services Agreement; the following description summarizes material functions and limits.

3. FEES, SETTLEMENT, AND RESERVES

PSP discloses the material fees and settlement practices applicable to Client, including processing rates, per-transaction fees, chargeback fees, rolling or fixed reserves, and holdback practices. All fees invoiced by PSP or withheld from settlements shall be consistent with the Services Agreement and applicable law.

4. THIRD-PARTY RELATIONSHIPS

PSP hereby discloses that it uses third-party processors, gateways, subprocessors, acquiring banks, and fraud vendors in connection with the Services. Material third-party relationships and categories of services provided by such third parties will be disclosed to Client upon request and except where contractual confidentiality prohibits disclosure; PSP shall, in all events, comply with applicable law concerning subcontracting and data transfers.

5. DATA PROCESSING AND PRIVACY

PSP will process Cardholder Data and Personal Data only as necessary to perform the Services and in accordance with the data protection provisions in the Services Agreement. PSP shall implement and maintain technical and organizational measures appropriate to the risks presented by such processing.

6. SECURITY AND FRAUD PREVENTION

PSP represents that it maintains industry-accepted security standards, including, where applicable, Payment Card Industry Data Security Standard (PCI DSS) controls, encryption of data in transit and at rest, and procedures for monitoring and responding to suspected fraud. Client acknowledges that fraud losses may arise and agrees to the fraud mitigation measures described below.

7. COMPLIANCE AND ANTI-MONEY LAUNDERING

PSP shall conduct due diligence and ongoing monitoring consistent with applicable anti-money laundering and sanctions laws. Client shall provide all KYC/AML documentation reasonably required by PSP and shall promptly notify PSP of any materially adverse changes to Client's business or ownership.

Client acknowledges that failure to provide required information or the discovery of material misrepresentations may result in suspension or termination of Services and potential reporting to competent authorities.

I acknowledge and understand

8. CHARGEBACKS, DISPUTES AND RECONCILIATION

PSP's chargeback management process, including deadlines for evidence submission, liable party for chargebacks, and applicable chargeback fees, shall be as described in the Services Agreement. Client is responsible for timely reconciliations and for cooperating in dispute resolution.

9. CONFIDENTIALITY

Each Party shall keep confidential and not disclose the other Party's Confidential Information except as required by law or as necessary for performance of the Services. Confidential Information excludes information that is publicly available through no breach by the receiving Party or independently developed by the receiving Party without reference to the disclosing Party's information.

10. INDEMNIFICATION

Each Party shall indemnify, defend and hold harmless the other Party from and against all third-party claims, liabilities, losses, and expenses (including reasonable attorneys' fees) arising out of the indemnifying Party's breach of this Disclosure, gross negligence, willful misconduct, or failure to comply with applicable laws in connection with the Services.

11. LIMITATION OF LIABILITY

Except to the extent prohibited by applicable law, neither Party shall be liable to the other for incidental, consequential, special, punitive, or exemplary damages arising out of or in connection with this Disclosure or the Services, whether in contract, tort, strict liability, or otherwise. The Parties may allocate liability for direct damages in the Services Agreement.

12. TERM AND TERMINATION

13. NOTICES

All notices required or permitted under this Disclosure shall be in writing and delivered to the addresses set forth below or to such other address as a Party may designate in writing pursuant to this section.

14. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment, modification or waiver of any provision of this Disclosure shall be effective unless in writing and signed by authorized representatives of both Parties. No failure or delay by either Party in exercising any right under this Disclosure shall operate as a waiver. This Disclosure may be executed in counterparts, each of which shall be an original and all of which together shall constitute one instrument.

15. GOVERNING LAW

This Disclosure shall be governed by and construed in accordance with the laws of the State of without regard to its conflict of laws principles.

16. ENTIRE AGREEMENT; SEVERABILITY

This Disclosure, together with the Services Agreement, constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous representations and agreements regarding such subject matter. If any provision of this Disclosure is held to be invalid or unenforceable, such provision shall be severed and the remaining provisions shall continue in full force and effect.

CERTIFICATION AND ACKNOWLEDGEMENT

Each Party certifies that the disclosures above accurately reflect PSP's material practices known to the signing representative at the time of signing, and that the signing representative has authority to accept and bind the Party. Each Party further acknowledges that it has received an opportunity to review this Disclosure and to ask questions directed to the designated compliance contact.

Client acknowledgment of receipt of this Disclosure:

Client acknowledges receipt and understanding of this Disclosure

Payment Service Provider

Party Label:

By:

Date:

Client

Party Label:

By:

Date:

Enter text✕

What the Legal PSP Disclosure Form Is and when it applies

The Legal PSP Disclosure Form documents disclosures required when a payment service provider (PSP) or third-party settlement provider handles legal payments, settlements, or escrow services on behalf of a party. It records the provider’s identity, scope of services, fees, data handling practices, and any conflicts of interest, and it creates an auditable record for compliance, client notice, and dispute resolution. The form is commonly used where state or federal consumer-finance, escrow, or fiduciary rules require advance notice or where the parties prefer an explicit written allocation of responsibilities for funds, recordkeeping, and record retention.

Why a clear disclosure matters for legal and operational certainty

A properly completed Legal PSP Disclosure Form reduces ambiguity about who controls funds, who bears fees and losses, and how confidential or regulated data will be handled. It supports statutory compliance, strengthens enforceability of payment arrangements, and creates a defensible audit trail for disputes or regulatory review.

Why a clear disclosure matters for legal and operational certainty

Who typically completes or receives this disclosure

The form is used by counterparties that send or receive funds through a PSP, in-house treasury teams, third-party escrow agents, counsel, and compliance officers.

  • Payment Service Providers and escrow agents who must disclose fees and responsibilities.
  • Corporate treasury, finance, and legal teams documenting third-party payment arrangements.
  • Counsel and compliance officers preparing records for audits and regulatory review.

Use the form early in contract formation or when a new payment channel is added to avoid downstream disputes and ensure required consumer or institutional notices are delivered.

Primary signer roles

PSP Authorized Signatory

An officer or designated agent with authority to bind the payment service provider. The signer confirms fees, controls over funds, data-handling commitments, and acceptance of responsibility for the described services.

Client Representative

A client officer, controller, or authorized agent who accepts the PSP terms on behalf of the payer/recipient and confirms the accuracy of business identity, account details, and consent to electronic delivery where required.

Core components to include in a professional PSP disclosure

A robust Legal PSP Disclosure Form is organized into standard sections that capture identity, scope, fees, data handling, dispute procedures, and signature blocks to ensure clarity and enforceability.

Provider Identity

Legal name, DBA, business address, and regulatory registration numbers where applicable.

Scope of Services

Specific payment, settlement, escrow, or reconciliation activities the PSP will perform and any excluded services.

Fees and Charges

Itemized fees, fee timing, chargeback handling, and who is responsible for network or interchange costs.

Funds Control

Whether funds are held in trust, commingled, or remitted immediately; timing of settlement and reconciliation procedures.

Data Handling

Types of data collected, retention period, security measures, and HIPAA or other compliance notes when applicable.

Dispute & Liability

Notice procedures, limitation of liability clauses, indemnities, and applicable governing law.

Step-by-step: completing the Legal PSP Disclosure Form

Follow these sequential steps to prepare, verify, and execute the disclosure so it is clear, enforceable, and audit-ready.

  • 01
    Gather documentation: Collect provider agreements, licenses, and fee schedules.
  • 02
    Complete identity fields: Enter legal names, addresses, and tax identifiers.
  • 03
    Describe services: Write precise, limited scope language to avoid implied obligations.
  • 04
    Execute signatures: Sign with authorized representatives and record dates.

Typical workflow for form review and execution

This sequence represents a common routing flow from preparation to archive; adapt steps to internal approval and compliance checkpoints.

  • Draft: Prepare the draft disclosure using contract templates and input from finance.
  • Internal review: Legal and compliance review for regulatory consistency.
  • Provider review: Send to PSP for acceptance or negotiated changes.
  • Execute and archive: Sign, distribute copies, and store for retention period compliance.

Configuring a digital workflow for the disclosure

Use these settings to build a consistent, auditable e-delivery and signature flow for the form.

Field Configuration
Signature order Sequential or parallel routing
Authentication Email + SMS code or KBA as needed
Attachments Attach fee schedules or licenses
Retention hook Auto-archive to records system

Technical capabilities to support digital completion and storage

Confirm your platform supports secure upload, audit trails, and integrations before issuing the disclosure.

  • File formats: PDF, DOCX, and fillable forms supported
  • Integrations: Salesforce, NetSuite, Microsoft 365, Google Workspace
  • Security: TLS in transit; AES-256 at rest

Ensure the platform provides tamper-evident storage, role-based access, and an exportable audit trail for compliance reviews.

Mandatory information fields to collect

Full Legal Name: Legal entity name
Tax Identifier: EIN or SSN
Bank Account: Routing and account number
Service Description: Detailed service scope
Fee Schedule: Itemized fees
Data Handling: Security and retention

Practical tips for accurate and efficient completion

Use consistent, verified data and a controlled template to reduce rework and support compliance.

Use a standard template
Maintain one approved form to avoid inconsistent clauses and omissions.
Verify signatory authority
Confirm via corporate documents or an officer certificate before accepting signatures.
Attach supporting documents
Include license, fee schedule, and insurance proof to avoid follow-ups.
Preserve audit trail
Record IP, timestamps, and authentication method for each signer.

Common errors that delay acceptance

  • Missing or mismatched legal names cause verification failures and banking holds.
  • Vague scope language creates disputes about whether the PSP accepted a responsibility.
  • Unclear fee allocation leads to unexpected chargebacks or reimbursement claims.
  • Absent or incomplete signature blocks void acceptance by counterparties or banks.

Key legal and financial risks from an incorrect disclosure

1099 Penalties: Incorrect reporting can trigger IRC §6721 penalties ($60–$330 per form).
Backup Withholding: Missing TIN may trigger 24% backup withholding.
I-9 Violations: Improper documentation risks fines under 8 CFR §274a.2.
HIPAA Breach Exposure: Inadequate safeguards can create HIPAA liability; BAA required.
Contractual Disputes: Ambiguous terms increase litigation and recovery costs.
Regulatory Sanctions: Failure to disclose may result in agency fines or license issues.

Key deadlines and processing expectations

Track critical dates for tax reporting, retention, and dispute notices to avoid statutory penalties and meet audit requirements.

Delivery of Disclosure:

Provide prior to first settlement or as contract specifies

Tax Reporting:

Follow IRS reporting deadlines for 1099s (Jan 31 or as required)

Retention Start:

Retention triggers from execution date

Dispute Notice:

Follow contract notice windows for chargeback or reconciliation

Regulatory Filings:

Meet state licensing or registration renewal dates

Typical milestones from preparation to archive

A clear milestone timeline helps teams coordinate review, signature, and long-term storage for regulatory and operational needs.

01

Draft Completion

Prepare the initial disclosure and attach supporting documents.

02

Internal Approval

Legal and finance approve language and fees.

03

Counterparty Acceptance

PSP or client reviews and signs the form.

04

Archive and Retention

Store executed copies in records system and set retention triggers.

Comparing eSignature options commonly used for Legal PSP Disclosure Forms

These vendor criteria help evaluate pricing, bulk send, audit capabilities, and HIPAA compliance. signNow appears first for consistent comparison.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Real-world examples of PSP disclosures in practice

These examples show how organizations structured disclosures to reflect operational realities and compliance needs.

Optica Ventures (COO)

Optica used a concise disclosure to document escrow handling and fee splits for investor contributions

  • The form clarified settlement timing
  • The result reduced reconciliation queries and produced an auditable record for investor reports and audits.

Martin Properties (Founder)

Martin Properties implemented a disclosure when using a third-party payment processor for rent collections

  • The form specified remittance timing and chargeback rules
  • This reduced accounting disputes and improved tenant onboarding speed while preserving compliance with state landlord-tenant notice rules.

Frequently asked questions and quick troubleshooting

Answers to common questions about preparing, signing, and storing the Legal PSP Disclosure Form.


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