Business Related Parties Questionnaire

BUSINESS RELATED PARTIES QUESTIONNAIRE

Requesting Party Name:

Responding Entity Name:

Date of Questionnaire:

RECITALS

WHEREAS, Requesting Party requires full disclosure of business relationships and affiliations of the Responding Entity in order to evaluate potential conflicts of interest and to comply with applicable contractual obligations; and

WHEREAS, Responding Entity represents that the information provided in this Questionnaire will be accurate and complete to the best of its knowledge as of the date set forth below and recognizes that material omissions or misrepresentations may constitute a breach of agreement between the parties;

WHEREAS, the parties intend that the disclosures provided herein will be used by Requesting Party to assess related-party exposure and to determine whether restrictions, mitigations, or additional disclosures are required.

SCOPE OF WORK

RELATED PARTIES DISCLOSURE

Provide detailed information for each related party (individuals or entities) with which the Responding Entity has a material relationship, ownership interest, or contractual arrangement. Attach additional pages if necessary.

RELATED PARTY 1

RELATED PARTY 2

CONFLICTS, AGREEMENTS, AND PAYMENTS

Has the Responding Entity or any Related Party engaged in material business dealings, provided goods or services, or received compensation from the Requesting Party or its affiliates within the past 24 months?

PAYMENT TERMS (IF APPLICABLE)

TERM AND TERMINATION

This Questionnaire and any obligations arising from disclosures herein are effective as of: Start Date: and continue until: End Date:

Either party may terminate obligations created by this Questionnaire for material breach or for convenience upon written notice in accordance with the notice period above. Termination does not relieve either party of obligations accrued prior to termination.

CONFIDENTIALITY

All information provided in response to this Questionnaire is Confidential Information of the Responding Entity unless otherwise indicated in writing. Requesting Party shall: (a) restrict access to such Confidential Information to employees, agents, and advisors who have a need to know and who are bound by confidentiality obligations at least as protective as those set forth herein; (b) use the Confidential Information solely to evaluate related-party exposure and compliance; and (c) not disclose Confidential Information to third parties without prior written consent, except as compelled by law, in which case Requesting Party shall provide prompt notice to the Responding Entity to allow it to seek protective relief.

GOVERNING LAW

This Questionnaire and any disputes arising out of or related to the disclosures herein shall be governed by and construed in accordance with the laws of:

ENTIRE AGREEMENT

The representations, disclosures, and certifications set forth in this Questionnaire constitute the entire agreement between the parties with respect to the subject matter hereof and supersede all prior or contemporaneous understandings, agreements or communications, whether written or oral, relating to the same subject matter.

CERTIFICATION AND ACKNOWLEDGMENT

By signing below, the undersigned certifies under penalty of perjury that the information provided in this Questionnaire is true, complete, and accurate to the best of their knowledge as of the date indicated. The undersigned acknowledges that material omissions or inaccuracies may constitute a breach of contract and may subject the Responding Entity to remedies provided under applicable law or agreement.

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