# ACH / DISBURSEMENT AUTHORIZATION
## Debt Recovery Experts, LLC

This form authorizes Debt Recovery Experts, LLC ("DRE") to disburse recovered funds (net of contingency fee and itemized costs) to the Client's bank account identified below.

## Account Holder Information

| Field | Value |
|---|---|
| **Account holder legal name** (must match W-9) | {{account_holder_name}} |
| Entity type (if business) | {{account_holder_entity_type}} |
| Bank name | {{bank_name}} |
| Account type | [ ] Checking  [ ] Savings |
| Routing (ABA) number | {{routing_number}} |
| Account number | {{account_number}} |

## Authorization

The undersigned authorizes DRE to initiate **credit (deposit) entries only** to the account identified above for the purpose of disbursing settlement proceeds. This authorization is for **deposits only** — DRE is **not** authorized to debit this account for any reason.

This authorization remains in effect until revoked in writing by the undersigned.

## Tax Reporting

The undersigned acknowledges that recovered funds may be subject to tax reporting, and that DRE requires a valid IRS Form W-9 on file before any disbursement. DRE will not disburse funds without a completed W-9.

| | |
|---|---|
| **Client Signature** | **Date** |
| ________________________ | ________________________ |
| **Print Name** | **Title** |
| ________________________ | ________________________ |
| **Company (if applicable)** | |
| ________________________ | |