Citizenship Case Duplicate Form

Citizenship Case Duplicate Form

This Citizenship Case Duplicate Form is made and entered into by Applicant Name: (Applicant) and Requesting Party Name: . Execution Date: , .

RECITALS

WHEREAS, Applicant is the individual identified by Alien Registration Number: and seeks certified duplicates of documents related to Applicant's citizenship matter;

WHEREAS, Requesting Party has requested from the governmental custodian access to and certified duplicates of the case file and related certificates for Case Number: ; and

WHEREAS, the parties desire to set forth the terms on which duplicates shall be requested, delivered, and used, and to allocate responsibilities for fees, indemnity, and confidentiality.

NOW THEREFORE, in consideration of the mutual covenants contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. REQUEST FOR DUPLICATE

1.1 Request. Applicant authorizes Requesting Party to request and obtain certified duplicate(s) of the following records: Certificate Number: ; Documents Requested (describe):

1.2 Number of Copies. Number of certified duplicates requested:

1.3 Method of Delivery (select applicable):

Mail In person pickup Courier

2. REPRESENTATIONS, CERTIFICATIONS AND DECLARATION

2.1 Applicant represents and certifies under penalty of perjury under the laws of the governing jurisdiction that Applicant is the person named herein and that the information provided in this Form is true, complete and correct to the best of Applicant’s knowledge. Applicant further certifies that the duplicate is requested for legitimate use and not for fraud or misrepresentation.

2.2 Reason for Duplicate (check applicable):

Lost Destroyed Stolen Other

3. AUTHORIZATION TO RELEASE AND RECEIVE RECORDS

3.1 Applicant authorizes any governmental custodian, agency or official having custody of the records described in Section 1 to release certified duplicate copies to Requesting Party. This authorization includes the release of all documents reasonably necessary to locate, identify, verify and certify the requested documents.

3.2 Requesting Party shall use duplicates only for the purpose stated in this Form and shall not permit third-party disclosure except as required by law or pursuant to further written authorization by Applicant.

4. FEES, PAYMENT AND INDEMNITY

4.1 Fees. Applicant acknowledges that fees, certification charges, copying costs and any courier charges may apply. Requesting Party may pay fees on Applicant’s behalf; Applicant remains responsible for reimbursement of such charges.

4.2 Indemnity. Requesting Party and Applicant, jointly and severally, shall indemnify, defend and hold harmless the governmental custodian and its employees and agents from and against any claims, liabilities, losses, damages, costs, or expenses (including reasonable attorneys' fees) arising from reliance on the representations in this Form, any misuse of the duplicates, or any false statement herein.

5. CONFIDENTIALITY AND PROHIBITED USE

5.1 Confidentiality. Requesting Party shall maintain the confidentiality of all copies in a secure manner and shall limit access to authorized personnel only. Requesting Party shall promptly notify Applicant in the event of any unauthorized disclosure, loss, or theft of duplicates.

5.2 Prohibited Use. Duplicates shall not be used for immigration fraud, identity theft, or any activity that would knowingly violate any statute or regulation. Breach of this Section shall entitle Applicant to injunctive relief and recovery of damages.

6. LIMITATION OF LIABILITY

6.1 Except for willful misconduct or gross negligence, neither party shall be liable for incidental, special, consequential or punitive damages arising from the performance of this Form, even if advised of the possibility of such damages.

7. NOTICES

All notices under this Form shall be in writing and delivered to the addresses set forth below by certified mail, courier, or personal delivery. Notices are effective upon receipt.

8. GOVERNING LAW

This Form shall be governed by and construed in accordance with the laws of the state specified by the parties: State of , without regard to conflict of law principles.

9. ENTIRE AGREEMENT

This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals, and communications, whether written or oral.

10. SEVERABILITY

If any provision of this Form is held to be invalid, illegal or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect and shall be interpreted so as to effectuate the original intent as closely as possible.

11. AMENDMENT; WAIVER; COUNTERPARTS

Any amendment or modification of this Form must be in writing and signed by both parties. Failure to enforce any provision shall not constitute a waiver of that provision. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

12. ADDITIONAL INFORMATION

Month Day Year

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