Payment Debit Form

PAYMENT DEBIT FORM

RECITALS

WHEREAS, Client Name: (the "Client") desires to procure services or goods from Payee Name: (the "Payee"); and

WHEREAS, the Parties wish to authorize automatic debit payments from the Client's deposit account in satisfaction of invoices or recurring fees described in this Payment Debit Form and any attached agreement; and

WHEREAS, the Parties intend to set forth the scope, payment terms, authorization, and legal provisions governing such debit transactions.

SCOPE OF WORK

PAYMENT TERMS

Payment Amount:   Currency:

Monthly    Semi-monthly    Weekly    One-time

If periodic, Payment Day or schedule detail:

First debit effective date:   Next anticipated debit date:

Late fee (if payment not received when due):   or Flat fee:   Returned item fee:

DEBIT AUTHORIZATION & BANK INFORMATION

Bank Name:

Account type:    Checking    Savings    Other:

By signing below, Client authorizes Payee to initiate debit entries and, if necessary, credit entries and adjustments for any debit entry made in error to the account designated above. This authorization permits debits for the amounts and on the schedule set forth in this Payment Terms section and for any final reconciliation amounts due under the Scope of Work described above.

TERM AND TERMINATION

Agreement Start Date:   Agreement End Date (if applicable):

Either Party may terminate this authorization for convenience upon written notice to the other Party delivered at least days prior to the next scheduled debit. Termination does not relieve the Client of liability for amounts already debited or accrued prior to termination.

Termination for cause (including material breach or fraudulent activity) may be immediate upon notice. Client agrees to remain responsible for any amounts due through the date of termination and for any reasonable costs incurred to effect collection.

CONFIDENTIALITY

Each Party shall hold in strict confidence all non-public financial information, account numbers, business terms, and other proprietary information received from the other Party in connection with this Payment Debit Form, and shall not disclose such information except as required by law or with the prior written consent of the disclosing Party. This obligation survives termination of this authorization for a period of two years.

LIABILITY, INDEMNITY & WARRANTIES

Client represents and warrants that the account information provided is correct and that Client is authorized to allow debits from the specified account. Payee will use commercially reasonable procedures to process debits and to safeguard account information. Client agrees to indemnify and hold harmless Payee from any third-party claims, losses, or damages resulting from Client's breach of representations, negligence, or fraudulent acts.

In the event of an incorrect debit, the Parties will cooperate to resolve the error promptly. Client retains all rights to dispute unauthorized or erroneous debits under applicable banking rules and regulations.

GOVERNING LAW

This Payment Debit Form shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of laws principles.

ENTIRE AGREEMENT

This form, together with any written attachments or schedules executed by the Parties, constitutes the entire agreement between the Parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements, representations, and understandings, whether written or oral.

Amendments to this Payment Debit Form must be made in writing and signed by both Parties. No oral promises or representations shall have any force or effect.

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