I hereby agree and contend that I have authorization from my organization to receive payouts at the included account. I also understand and agree that I am responsible for returning any and all refunds that may occur on the included payout funds and that MJS Software (dba PTOffice) can/will recover these funds by deducting the funds from any future payouts. In the event of non-sufficient funds being available for recovering in future payouts, MJS Software (dba PTOffice) will invoice our organization accordingly and I am responsible for payment in full within 15 days.

I also understand that this information is correct and understand that any mistyped information may result in lost funds which are not recoverable.