Application Duplicate Form

APPLICATION DUPLICATE FORM

Use this form to request a duplicate copy of a previously submitted application and to establish the terms under which the duplicate will be produced and delivered. Complete all required fields, sign where indicated, and submit the appropriate fee. Production of duplicates is subject to verification of identity and payment of applicable fees.

RECITALS

WHEREAS, the Applicant submitted an original application to the Issuing Entity and the Issuing Entity maintains a record of that original application; and

WHEREAS, the Applicant requests a duplicate copy of certain documents related to the original application and agrees to pay the applicable duplication and processing fees; and

WHEREAS, the Issuing Entity is willing to provide the duplicate subject to verification of identity, payment, and the terms set forth in this Agreement.

APPLICANT INFORMATION

ORIGINAL APPLICATION DETAILS

Date Filed:    Issuing Department:

Requested Duplicate Items

Certified copy (includes official seal)

Uncertified copy

Electronic copy (PDF)

Full file reproduction (all pages on record)

SCOPE OF REQUEST / SCOPE OF WORK

PAYMENT TERMS

Fees due for duplication and processing are set forth below. Applicant acknowledges that production will not begin until payment is received and identity is verified.

Fees are non-refundable except as required by applicable law. Late payments incur the late fee described above and interest at the maximum lawful rate permitted. Applicant shall be responsible for costs of collection, including reasonable attorney fees.

TERM AND TERMINATION

This Agreement commences on the Start Date and, unless earlier terminated, continues until the End Date or until the duplicate request has been fulfilled and fees satisfied.

Start Date:    End Date:

Either party may terminate this Agreement by providing the other party with the notice period indicated above. Termination does not relieve Applicant of liability for fees incurred prior to termination.

CONFIDENTIALITY

All non-public information exchanged in connection with the duplicate request shall be treated as confidential and used solely to effectuate the production and delivery of the duplicate documents, except as required by law or court order. The Issuing Entity shall endeavor to protect Applicant information in accordance with its records retention and privacy policies.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to conflicts of law principles.

ENTIRE AGREEMENT

This document constitutes the entire agreement between the Applicant and the Issuing Entity with respect to the duplicate request and supersedes all prior written or oral understandings. Any modification must be in writing and signed by authorized representatives of both parties.

CERTIFICATION AND AUTHORIZATION

By signing below, the Applicant certifies under penalty of perjury that the information provided in this form is true and correct to the best of the Applicant's knowledge and that the Applicant is entitled to request the duplicate documents. Applicant authorizes the Issuing Entity to reproduce and deliver copies of records as requested and to charge the fees set forth above.

Identification Provided (type and ID number):

Processing Time Requested:

Applicant Acknowledgement: I acknowledge that fees may be required and that duplicates may be withheld until payment and identity verification are complete.

Sign Now