Beneficial Ownership Declaration Form

BENEFICIAL OWNERSHIP DECLARATION FORM

This Beneficial Ownership Declaration Form (the "Declaration") is made effective as of by and between Reporting Company: formed under the laws of , and Recipient: .

RECITALS

WHEREAS, the Recipient requires accurate and verified information regarding natural persons who, directly or indirectly, own or exercise substantial control over the Reporting Company for purposes of legal, regulatory and compliance review; and

WHEREAS, the Reporting Company desires to provide a certification of beneficial ownership and to warrant that the information provided herein is true, complete and correct to the best of its knowledge and belief; and

WHEREAS, the parties intend that this Declaration constitute a legally binding statement by the Reporting Company and its authorized representative to the Recipient.

NOW, THEREFORE

In consideration of the mutual covenants set forth below, the parties agree as follows:

1. DEFINITIONS

For purposes of this Declaration, the following terms shall have the meanings set forth below: (a) "Beneficial Owner" means any natural person who, directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise: (i) exercises substantial control over the entity; or (ii) owns or controls, directly or indirectly, 25% or more of the ownership interests of the entity, unless a different threshold is required by applicable law; (b) "Control" or "controls" means the power, whether formal or informal, to direct, influence or determine important matters affecting the entity.

2. REPORTING COMPANY INFORMATION

Corporation    Limited Liability Company (LLC)    Partnership    Trust    Other:

3. IDENTIFICATION OF BENEFICIAL OWNERS

The Reporting Company identifies the following natural persons as Beneficial Owners, who meet the definition set forth in Section 1. For each person listed, provide the requested information and attach certified copies of identification documents where required by the Recipient's policy.

Beneficial Owner 1

Month Day Year

This individual exercises substantial control over the Reporting Company.

Beneficial Owner 2

Month Day Year

This individual exercises substantial control over the Reporting Company.

Beneficial Owner 3 (if applicable)

Month Day Year

This individual exercises substantial control over the Reporting Company.

If additional Beneficial Owners exist, attach a signed and dated schedule containing the same information and mark below:

Additional Beneficial Owner Schedule attached

4. REPRESENTATIONS AND WARRANTIES

The Reporting Company, by its undersigned authorized representative, hereby represents and warrants to the Recipient that: (a) the information provided in this Declaration is true, correct and complete in all material respects; (b) the Reporting Company has made reasonable inquiry and exercised due diligence to identify each Beneficial Owner required to be disclosed; (c) it will promptly amend this Declaration and notify the Recipient in writing within thirty (30) days of any change in the information provided herein; and (d) the undersigned is authorized to make this certification on behalf of the Reporting Company and understands that materially false statements or omissions may subject the Reporting Company and the undersigned to civil or criminal penalties under applicable law.

5. USE, CONFIDENTIALITY AND RECORDKEEPING

The Recipient may use the information provided in this Declaration for verification, due diligence, recordkeeping and regulatory compliance purposes. The Recipient shall protect personal data in accordance with its internal policies and applicable law; provided, however, that the Recipient may disclose such information to governmental authorities, auditors, and third parties as required by law or regulation.

6. INDEMNIFICATION

The Reporting Company agrees to indemnify and hold harmless the Recipient and its officers, directors and agents from and against any claims, losses, liabilities, costs or expenses (including reasonable attorneys' fees) arising from or related to any material misrepresentation, omission or breach of the warranties contained in this Declaration.

7. NOTICES

All notices, requests and other communications required or permitted under this Declaration shall be in writing and delivered to the address provided by each party in this form or to such other address as either party may designate in writing.

8. AMENDMENTS; WAIVER; COUNTERPARTS

This Declaration may be amended only by a written instrument executed by both parties. No waiver of any provision shall be effective unless in writing and signed by the party waiving compliance. This Declaration may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Declaration shall be governed by and construed in accordance with the laws of the jurisdiction of the Reporting Company's formation, without regard to principles of conflict of laws. This Declaration constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior understandings. If any provision of this Declaration is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

10. AUTHORIZED REPRESENTATIVE OF REPORTING COMPANY

The undersigned certifies, under penalty of perjury, that the information provided in this Declaration is true and correct and that the undersigned is authorized to make this certification on behalf of the Reporting Company.

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