Payment Preference Form

PAYMENT PREFERENCE FORM

Use this form to designate your preferred method to receive payments. Complete all applicable sections, provide supporting documentation when requested, and ensure the authorized signatory executes the certification at the end. Submission of false or incomplete information may delay payment processing.

Payee Information

Payer / Account Reference

Payment Method Selection (select all that apply)

ACH / Direct Deposit

Wire Transfer

Check by Mail

Card Payment / Card on File

Electronic Payment Platform (e.g., ACH via third-party, digital wallet)

Authorization, Certifications, and Terms

By completing and signing this form, Payee certifies that all information provided is true, complete and accurate, that Payee has full authority to authorize the designated payment method(s), and that Payee will notify Payer promptly of any change in banking or mailing instructions. Payee authorizes Payer and Payer's financial agents to initiate credits and, if necessary to correct erroneous credits, initiate debits to the designated account in accordance with the selected method. This authorization remains in effect until Payer receives written notice of revocation and has had a reasonable opportunity to act on it.

Payee warrants and represents that the account information submitted belongs to Payee or Payee's authorized representative. Payee agrees to indemnify, defend, and hold harmless Payer for any loss, cost or expense (including reasonable attorneys' fees) arising from inaccurate information, unauthorized instructions, or Payee's failure to notify Payer of changes in a timely manner. Payer's liability for errors or delays will be limited to correction of the error or reimbursement of direct losses proven to result solely from Payer's gross negligence or willful misconduct.

Payee acknowledges that some payment methods may carry fees, currency conversion costs, or delays (including international wire processing times). Payee is responsible for confirming applicable fees and providing all required documentation to allow timely payment. Payer may, at its discretion, withhold payment until required documentation is received and verified.

This form and any disputes arising under it shall be governed by the laws of the jurisdiction identified by the payer in its corporate filings or payment terms, without regard to conflict-of-law principles. Payee consents to electronic communication for payment notices and remittance information unless Payee expressly requests otherwise in writing.

Additional Instructions

Acknowledgment

By signing below, Payee affirms that Payee has read and agrees to the authorization, certifications, and terms contained in this form. Payee further authorizes Payer to rely on electronically transmitted copies of this form and associated documentation.

Sign Now