Bankruptcy Information Form

BANKRUPTCY INFORMATION FORM

This Bankruptcy Information Form is entered into by and between Client Name: ("Discloser") and Recipient Name: ("Recipient") effective as of .

RECITALS

WHEREAS, Discloser has been or may have been a debtor in a bankruptcy proceeding and possesses information relevant to Discloser's bankruptcy history, case details, and current status;

WHEREAS, Recipient requires an accurate and complete statement of such bankruptcy information for the purpose of evaluating financial obligations, claims, or ongoing transactions involving Discloser;

WHEREAS, Discloser agrees to provide truthful and complete information and to authorize limited record requests as provided herein.

NOW, THEREFORE, in consideration of the mutual covenants contained in this Form, the parties agree as follows:

1. DEFINITIONS

For the purposes of this Form, "Bankruptcy Proceeding" means any filing under the United States Bankruptcy Code or any foreign bankruptcy, insolvency, or reorganization statute. "Discloser" and "Recipient" have the meanings set forth above.

2. BANKRUPTCY HISTORY

Has Discloser ever filed for bankruptcy? Yes No

If Yes, list each bankruptcy case with court and case number below and provide a brief explanation in the space provided.

3. CASE DETAILS (ITEMIZE EACH CASE)

Case Number: Court:

Chapter (check all that apply): Chapter 7 Chapter 11 Chapter 13

Filing Date: Conversion Date (if applicable):

Trustee Name: Assigned Attorney:

Current status (select one): Pending Discharged Dismissed

If discharged, Date of Discharge:

4. ASSETS, LIABILITIES AND CLAIMS

5. EXPLANATION OF CIRCUMSTANCES

6. AUTHORIZATION TO OBTAIN RECORDS

Discloser authorizes Recipient and Recipient's agents to obtain bankruptcy pleadings, dockets, schedules, and related public records from relevant courts, trustees, or third-party record custodians solely for the purpose set forth in this Form. Discloser further authorizes third parties to release such records to Recipient upon presentation of a copy of this signed Form.

7. REPRESENTATIONS AND WARRANTIES; CERTIFICATION

Discloser represents and warrants that the information provided in this Form is true, correct, and complete to the best of Discloser's knowledge. Discloser acknowledges that providing materially false information may subject Discloser to civil and criminal liability under applicable law. Discloser certifies under penalty of perjury that the foregoing is true and correct.

8. CONFIDENTIALITY

Recipient will treat non-public information disclosed hereunder as confidential and will not disclose such information except (a) as required by law or court order, (b) to Recipient's counsel or auditors on a need-to-know basis, or (c) as necessary to enforce Recipient's rights. Recipient shall use reasonable measures to protect confidential information but shall not be liable for disclosures resulting from legal compulsion.

9. NOTICES

Notices are effective when received in writing at the addresses provided above or such other address as a party designates in writing.

10. GOVERNING LAW

This Form is governed by and construed in accordance with the laws of the state of without regard to conflict of laws principles.

11. ENTIRE AGREEMENT

This Form contains the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written.

12. SEVERABILITY

If any provision of this Form is held to be invalid, illegal or unenforceable, the remaining provisions shall remain in full force and effect and shall be construed so as to effectuate the intent of the parties to the maximum extent permitted by law.

13. AMENDMENTS; WAIVER; COUNTERPARTS

This Form may be amended only by a written instrument signed by both parties. No waiver of any provision shall be effective unless in writing and signed by the party against whom enforcement is sought. This Form may be executed in counterparts, each of which shall be an original and all of which together shall constitute one instrument.

14. ACKNOWLEDGMENT

BY SIGNING BELOW, Discloser certifies under penalty of perjury that the information provided in this Form is true, accurate and complete to the best of Discloser's knowledge. Recipient acknowledges receipt and agrees to the confidentiality and use provisions set forth herein.

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