Authorization to Release Account Information

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

DATE

{{date}}

SUBJECT: AUTHORIZATION TO RELEASE ACCOUNT INFORMATION

I, {{account_holder_name}}, of {{account_holder_address}}, hereby authorize {{third_party_name}}, of {{third_party_address}}, to access and receive information related to my account(s) held at {{bank_name}}, located at {{bank_address}}.

ACCOUNT DETAILS

This authorization applies to the following account(s):

Account Name: {{account_name}}

Account Number: {{account_number}}

Account Type: {{account_type}}

Additional Account Details (if applicable): {{additional_account_details}}

SCOPE OF AUTHORIZATION

The authorized individual/entity is permitted to receive the following information:

- Account balance statements dating from {{start_date}} to {{end_date}}.

- Transaction history for the period of {{start_date}} to {{end_date}}.

- Copies of bank statements for the period of {{start_date}} to {{end_date}}.

- Other specific information: {{other_authorized_information}}

This authorization does NOT extend to:

- Initiating transactions (e.g., withdrawals, transfers, payments).

- Changing account details (e.g., address, contact information).

- Closing the account(s).

- Any other actions not explicitly listed above.

PURPOSE OF DISCLOSURE

The information requested is for the purpose of: {{purpose_of_disclosure}} (e.g., loan application, financial review, legal proceedings, tax preparation).

VALIDITY

This authorization shall be effective from the date of signing and shall remain in effect until {{expiration_date}} or until I revoke it in writing, whichever comes first.

I understand that I may revoke this authorization at any time by providing written notice to {{bank_name}} and {{third_party_name}}.

LIABILITY WAIVER

I hereby release {{bank_name}}, its officers, agents, and employees from any liability for disclosing the aforementioned information to {{third_party_name}} in reliance upon this authorization.

GOVERNING LAW

This Authorization to Release Account Information shall be governed by and construed in accordance with the laws of {{country_name}}.

SIGNATURES

_____________________________

{{account_holder_name}}

Account Holder

Date: {{signature_date}}

_____________________________

{{third_party_name}}

Authorized Third Party (if required by bank or agreement)

Date: {{signature_date}}