Certificate Information Form

CERTIFICATE INFORMATION FORM

Parties and Identifying Information

Issuer Name:

Requester Name:

Recitals

WHEREAS, Issuer is duly authorized to prepare and issue certificates regarding the matters described herein and has agreed to provide a certificate at the request of Requester; and

WHEREAS, Requester has provided information and documentation to Issuer for the purpose of preparing a certificate identified below and warrants that the information submitted is true, complete, and accurate to the best of Requester's knowledge; and

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

Certificate Details

Date of Issue:    Expiration Date:

Scope of Work

The parties agree that Issuer's obligations in connection with issuance of the certificate are limited to the services described below and do not include verification of matters outside the scope set forth by Requester.

Payment Terms

Requester shall pay Issuer for preparation and issuance of the certificate in accordance with the terms set forth below.

Term and Termination

This Certificate Information Form is effective as of the Start Date and remains in effect until the End Date unless earlier terminated pursuant to the provisions below.

Start Date:    End Date:

Either party may terminate this agreement for material breach by the other party if such breach is not cured within the notice period set forth above following written notice.

Confidentiality

Each party agrees that all non-public information furnished by one party to the other in connection with the preparation or issuance of the certificate is confidential and shall not be disclosed to third parties except (i) as required by law or valid subpoena, (ii) to the party's legal or financial advisors under obligations of confidentiality, or (iii) with the prior written consent of the disclosing party.

Acknowledgement of confidentiality obligations: I acknowledge and agree to the confidentiality provisions above.

Representations; Warranties; Certification

Requester represents and warrants that all information submitted to Issuer for the purpose of preparing the certificate is true, complete, and accurate. Requester understands that Issuer will rely on submitted materials and that Issuer has no obligation to independently verify factual assertions unless expressly contracted to do so.

Governing Law

This Certificate Information Form shall be governed by and construed in accordance with the laws of the state specified below without regard to its conflicts of law principles.

Entire Agreement

This form, together with any attachments or exhibits expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written. Any amendment must be in writing and signed by both parties.

Acknowledgment and Certification

By signing below, each party certifies under penalty of perjury that the information provided on this Certificate Information Form is true and accurate, and that they are authorized to execute this form on behalf of the party identified.

WARNING: Providing false information may subject the signer to civil and criminal penalties.

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