DISBURSEMENT REQUEST AND AUTHORIZATION
BUYER:
_____________________________________ (Company) _____________________________________ (Address) _____________________________________
SELLER:
_____________________________________ (Company) _____________________________________ (Address) _____________________________________
Seller understands that no proceeds will be disbursed until all of Buyers conditions for making the initial advance have been satisfied. Buyer is hereby directed to and authorized to release the proceeds under that certain Factoring Agreement by and between Seller and Buyer dated ________(month & day), ______(year) to the parties listed below in the amounts specified:
1. 2. 3. 4.
_____________________________________ (Co.) _____________________________________ (Co.) _____________________________________ (Co.) _____________________________________ (Co.)
$__________________ $__________________ $__________________ $__________________
Total Disbursements
$___________________
Date of Authorization: _________________
SELLER: __________________________________ (Co.)
BY: _______________________________________ (President)