Third Party Authority Form

Third Party Authority Form

This Third Party Authority Form ("Agreement") is entered into as of the Effective Date by and between Principal: and Authorized Representative: .

Recitals

WHEREAS, Principal maintains accounts, records, and other matters identified below and desires to permit a third party to access, inspect, obtain copies of, and act with respect to such accounts or records on the terms set forth herein;

WHEREAS, Authorized Representative is willing to accept such authority subject to the limitations and conditions set forth in this Agreement and any required identification or verification procedures;

WHEREAS, the parties intend that third-party recipients relying on this document may accept copies or electronic versions as conclusive evidence of the authority granted.

NOW THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

1. Appointment and Grant of Authority

Principal hereby appoints Authorized Representative as its authorized agent and attorney-in-fact, with authority to act on Principal's behalf for the purposes and to the extent described in Section 2. The authority granted is limited to the acts expressly set forth in this Agreement and shall not be construed to grant any authority beyond those acts.

2. Scope of Authority

The authority granted to Authorized Representative includes, subject to the box selections and any written limitations below, the following actions with respect to the accounts, records, or matters identified in this Agreement:

3. Accounts and Identifiers

This authority applies to the following accounts, records or matters (identify by name of institution, account number, policy number, or other identifying information):

4. Effective Date; Term; Termination

This Agreement is effective as of Effective Date: and shall continue until Termination Date: or until revoked in accordance with Section 5 below.

5. Revocation

Principal may revoke this authority at any time by providing written notice of revocation to Authorized Representative and to any third party or institution reasonably expected to rely on this Agreement. Revocation shall be effective upon receipt by the third party but shall not affect any actions taken by Authorized Representative in good faith prior to receipt of such notice.

6. Representations and Warranties

Each party represents and warrants that it has full right, power, and authority to enter into this Agreement and to perform its obligations hereunder. Principal represents that the information provided herein is true, complete and accurate to the best of Principal's knowledge.

7. Indemnification

Principal shall indemnify and hold harmless Authorized Representative and any third party acting in reasonable reliance on this Agreement from and against any and all claims, liabilities, losses, damages, costs, and expenses (including reasonable attorneys' fees) arising out of or relating to acts performed by Authorized Representative within the scope of the authority granted herein, except to the extent caused by Authorized Representative's gross negligence or willful misconduct.

8. Confidentiality; Use of Information

Authorized Representative shall maintain the confidentiality of any non-public information obtained pursuant to this Agreement and shall use such information solely for purposes of performing the authorized acts. Authorized Representative shall not disclose or use information in a manner inconsistent with applicable law or the terms of this Agreement.

9. Notices

Notices under this Agreement shall be delivered to the addresses below by hand, certified mail, or other method that provides written proof of delivery:

10. Governing Law; Jurisdiction

This Agreement shall be governed by and construed in accordance with the laws of the state specified below, without regard to its conflict of laws 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; Amendment; Waiver; Severability

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings. This Agreement may be amended only by a written instrument executed by both parties. No waiver of any breach shall constitute a waiver of any other right. If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

12. Counterparts; Execution

This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. Facsimile, photocopy, or electronic signatures shall be treated as original signatures for all purposes.

13. Additional Acknowledgments

Authorized Representative acknowledges that third parties may require proof of identity or additional documentation prior to honoring this authority and that Principal remains responsible for notifying third parties of any limitations or revocations.

Principal and Authorized Representative Information

Certification

Each signatory certifies under penalty of perjury to the best of their knowledge that the information provided in this form is true, accurate, and complete and that they are authorized to execute this Agreement on behalf of the party indicated.

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