Chase will take reasonable steps to authenticate the

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Chase will take reasonable steps to authenticate the identity of the Third Party authorized above; however, we will not have any liability if we decline to release your account information because we are unable to authenticate the true identity of the authorized requestor seeking account information. This authorization will remain valid until revoked. To revoke your authorization, please write or call us using the contact information below. I/We hereby indemnify and forever hold Chase harmless from any and all actions and causes of actions, suits, claims, attorney’s fees, or demands against Chase, which I/we and/or my/our heirs may have resulting from Chase discussing, or declining to discuss, my/our account with the above-named requestor or person identifying himself/herself to be that requestor, or resulting from providing, or declining to provide, any documents or other information concerning the account to the requestor. Signed by: __________________________________________ _______________________________ (Signature) (Date)
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__________________________________________ (Printed Name) Signed by: __________________________________________ _______________________________ (Signature) (Date) __________________________________________ (Printed Name) Please return this completed form to: Regular mail: Chase Mail Code OH4-7302 P.O. Box 24696 Columbus, OH 43224-0696 Overnight mail: Chase Attn: Third Party Authorization Research 710 South Ash Street, Suite 200 Glendale, CO 80246-1989 Fax: 1-614-422-7575 (Free of charge from any Chase branch) If you have questions on the form, please call us at 1-800-848-9136 (1-800-582-0542 TTY). CR46236-BE FM101
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