Third Party Financial Statement

THIRD PARTY FINANCIAL STATEMENT

Parties and Identification

Requesting Party Name:

Third Party Provider Name:

Subject of Statement (Individual or Entity):

Subject Address or Identifier:

RECITALS

WHEREAS, Requesting Party has requested a written financial statement and verified financial information concerning the Subject of Statement for the purpose of evaluating creditworthiness, underwriting, or other commercial transaction; and

WHEREAS, Third Party Provider maintains records and performs services sufficient to prepare a statement of the Subject's financial condition and is willing to provide such statement subject to the terms and certifications set forth herein; and

WHEREAS, the parties wish to document the scope, representations, confidences, fees and limitations applicable to the Third Party Financial Statement.

SCOPE OF STATEMENT

The Third Party Provider shall prepare and deliver a written statement describing the Subject's financial condition as of the date(s) set forth below, based on Provider's records, confirmed information from the Subject, and other supporting documentation provided to Provider. The statement shall include at minimum: (a) a summary of assets and liabilities; (b) income and expense summaries for the preceding twelve (12) months where available; and (c) an explanation of material contingencies identified in Provider's records.

FINANCIAL SUMMARY (PROVIDER TO COMPLETE)

SUPPORTING DOCUMENTS

Documents relied upon in preparing this statement (check all that apply):

Bank statements    Tax returns    Pay stubs    Accounting records

PAYMENT TERMS

Fee for preparation of the Third Party Financial Statement: $ . Payment shall be due as set forth below.

Late payment shall incur interest at the rate of on any past due amount, and Provider may suspend delivery of the final statement until payment is received in full.

TERM AND TERMINATION

Engagement start date: . Engagement end date (if applicable):

Either party may terminate this engagement for convenience upon written notice given days prior to termination. Termination shall not relieve Requesting Party of its obligation to pay for services rendered and costs incurred through the effective date of termination.

CONFIDENTIALITY

The parties acknowledge that the information exchanged in connection with this Statement is confidential. Third Party Provider shall not disclose the Subject's non-public financial information except (a) as authorized in writing by Requesting Party or the Subject, (b) as required by law, regulation, or valid court order, or (c) to professional advisors on a need-to-know basis who are bound by confidentiality obligations. Requesting Party shall treat the Statement as confidential and shall not distribute the Statement outside its organization except to parties with a legitimate need and under obligations of confidentiality.

REPRESENTATIONS; DISCLAIMER

Third Party Provider represents that it will exercise reasonable care in preparing the Statement based on its records and the documents provided. Provider does not audit or independently verify all underlying records unless expressly agreed. The Statement is provided solely for the limited purpose identified in this document and may not be used for other purposes without Provider's prior written consent. Provider disclaims any liability to third parties for reliance on the Statement except as may be expressly provided in a separate written agreement signed by Provider.

GOVERNING LAW

This Agreement and any dispute, claim or controversy arising out of or relating to this Statement shall be governed by and construed in accordance with the laws of the state of without regard to its conflict of law principles.

ENTIRE AGREEMENT

This document constitutes the entire agreement between Requesting Party and Third Party Provider with respect to the subject matter hereof and supersedes all prior written and oral agreements and understandings between the parties concerning the Statement unless expressly stated otherwise in a separate written instrument signed by both parties.

CERTIFICATION AND AUTHORIZATION

By signing below, Third Party Provider certifies that, to the best of its knowledge and after reasonable inquiry, the information in the Statement is accurate and fairly presents the financial condition of the Subject as of the date(s) indicated. Requesting Party acknowledges that it has obtained any required authorization from the Subject to receive the Statement and consents to the release of the financial information described herein.

The parties further agree that any dispute arising under this Agreement shall first be the subject of good faith negotiation between authorized representatives. If negotiation fails, the parties may pursue any remedy available at law or in equity.

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