Business Statement Evidence Form

Business Statement Evidence Form

Parties and Business Identification

Company / Entity Name (Declarant):

Employer Identification Number (EIN) / Tax ID:     Date Business Established:

Sole Proprietorship    Partnership    Corporation    Limited Liability Company (LLC)    Other:

Other Party / Recipient Name:

Employer Identification Number (EIN) / Tax ID:     Contact Phone:

Recitals (Whereas)

WHEREAS, Declarant is engaged in the business described as and maintains records and documentation that substantiate the Declarant's operations and financial transactions; and

WHEREAS, Other Party requires documented evidence of the Declarant's business existence, ownership, and specified transactions for legitimate commercial, regulatory or contractual purposes; and

WHEREAS, the parties desire to set forth the terms under which Declarant will provide a formal business statement and supporting evidence to Other Party, and to allocate responsibilities, payment, confidentiality and governing law.

Scope of Statement and Evidence

Supporting documentation to accompany the business statement shall include (check applicable):

Articles of Incorporation / Organization    Operating Agreement / Partnership Agreement    Bank Statements    Tax Returns    Relevant Contracts / Invoices

Payment Terms

As consideration for the services and production of evidentiary documentation, Other Party shall pay Declarant the sum of $ in accordance with the following schedule:

Invoices issued by Declarant are payable within calendar days of invoice date. Overdue payments shall incur a late fee of , plus reimbursement of reasonable collection costs and attorneys' fees.

Term and Termination

Effective Date:     Termination Date (if any):

Either party may terminate this Agreement for convenience upon days' prior written notice to the other party. Either party may terminate immediately for material breach that remains uncured for a period of days after written notice of such breach.

Confidentiality

All non-public information, documentation, records, and data disclosed by either party in connection with this Agreement ("Confidential Information") shall be held in strict confidence and shall not be disclosed to third parties except as required by law or as necessary to perform the obligations under this Agreement. Each party shall use at least the same degree of care to protect Confidential Information as it uses to protect its own confidential information, and in no event less than a reasonable standard of care.

Confidential Information shall not include information that: (a) is or becomes publicly known through no act or omission of the receiving party; (b) was in the receiving party's lawful possession prior to receipt from the disclosing party; (c) is rightfully received from a third party without breach of any obligation of confidentiality; or (d) is independently developed by the receiving party.

Representations and Warranties; Certification

Declarant represents and warrants that the statements and documents provided pursuant to this Agreement are true, complete and accurate to the best of Declarant's knowledge, and that the person signing below is authorized to make this certification on behalf of the Declarant. Declarant acknowledges that Other Party may rely on such representations and that materially false or misleading statements may give rise to liability under applicable law.

Governing Law and Dispute Resolution

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to principles of conflicts of law. The parties agree that disputes arising under this Agreement shall be resolved in the state or federal courts located within that state, except where the parties agree in writing to mediation or arbitration.

Entire Agreement

This Agreement, together with any written attachments and exhibits expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, proposals and communications, whether oral or written. Any modification or amendment must be in a written instrument signed by both parties.

Additional Administrative Details

Acknowledgment

By signing below, each signatory affirms under penalty of perjury that the information provided in this Business Statement Evidence Form and accompanying documentation is true, accurate and complete to the best of their knowledge, and that they are authorized to bind the party on whose behalf they sign.

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