Accounts Receivable Transfer Agreement Form
Complete this form to document the transfer of accounts receivable between the transferor and transferee.
Parties and Agreement Details
Transfer Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Agreement / Reference Number
Transferor Legal Name
*
Transferee Legal Name
*
Transferor Contact Person
*
Transferor Contact Title
*
Transferee Contact Person
*
Transferee Contact Title
*
Effective Date of Transfer
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Receivables Portfolio Description
*
Accounts Receivable Portfolio Details
Original customer/debtor name(s)
*
Invoice or receivable description
Invoice date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Due date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Outstanding balance amount
*
Currency
*
Please Select
USD
EUR
GBP
CAD
AUD
Other
Number of invoices/receivables included
*
Aging / status notes
Transfer Terms and Conditions
Transfer Type
*
Full Assignment
Partial Assignment
Portfolio Transfer
Other
Transfer Price / Consideration Amount
Payment Terms
Responsibilities Retained by Transferor
*
Collection Rights After Transfer
*
Please Select
Assignee Only
Transferor Only
Shared
As Agreed in Writing
Other
Debtor Notice Requirement
*
Please Select
Immediate Written Notice
Notice Within 5 Business Days
Notice Within 10 Business Days
No Notice Required
Other
Warranties and Representations Summary
*
Attachments, Signatures, and Final Confirmation
Supporting Documents
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Transferor Authorized Signer Name
*
Transferor Signer Title
*
Transferee Authorized Signer Name
*
Transferee Signer Title
*
Transferor Signature
*
Transferee Signature
*
Signature Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Final Confirmation
*
I confirm the information provided is accurate and complete
Submit Agreement
Submit Agreement
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