Citizenship Status Questionnaire

Citizenship Status Questionnaire and Agreement

Client Name:     Requester/Company:

RECITALS

WHEREAS, the Company requires accurate and verifiable information regarding the citizenship and immigration status of certain individuals in order to comply with contractual, regulatory, and internal due diligence obligations; and

WHEREAS, the Respondent desires to provide such information and to confirm the accuracy of their citizenship status for the limited purposes set forth in this Questionnaire and Agreement; and

NOW, THEREFORE, in consideration of the mutual covenants and promises set forth below, the parties agree that the Respondent shall complete this Citizenship Status Questionnaire and that certain terms governing collection, use, confidentiality, and verification shall apply.

RESPONDENT INFORMATION

Date of Birth:     Place of Birth:

Contact Phone:     Email:

CITIZENSHIP / IMMIGRATION STATUS

Please indicate all statuses that apply (select all that apply):

United States citizen by birth
United States citizen by naturalization — Naturalization Date: Certificate No.:
Lawful Permanent Resident (Green Card) — A-Number: Card Issue Date:
Nonimmigrant Visa Holder — Visa Type: Expiration:
Refugee or Asylee — Grant Date:
Other:

Dual or Multiple Citizenship: Yes    Countries and details:

SCOPE OF WORK

PAYMENT TERMS

For services associated with verification and review of citizenship documentation, the Company shall pay:

Late Fee: If any payment is more than days late, interest shall accrue at per month, subject to applicable law.

TERM AND TERMINATION

This Agreement shall commence on and continue until , unless earlier terminated in accordance with this section.

Either party may terminate for convenience upon written notice delivered not less than days prior to the effective termination date. Termination for material breach may be immediate if the breaching party fails to cure within a period reasonably specified by the non-breaching party.

CONFIDENTIALITY

All information provided in this Questionnaire, including copies of identity and immigration documents, shall be treated as Confidential Information. Confidential Information shall not be disclosed except (i) as required by law, (ii) to the Company's agents or advisors on a need-to-know basis under obligations of confidentiality, or (iii) with the Respondent's prior written consent.

Respondent acknowledges and agrees to the Confidentiality provisions above.

GOVERNING LAW

This Questionnaire and Agreement shall be governed by and construed in accordance with the laws of the jurisdiction of , without regard to conflict of laws principles.

ENTIRE AGREEMENT

This document constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written statements, representations, or agreements relating to the same. Any amendment must be in writing and signed by both parties.

CERTIFICATION AND AUTHORIZATION

I certify, under penalty of perjury under the laws applicable to the Governing Law stated above, that the information and documents provided in this Questionnaire are true, correct and complete to the best of my knowledge. I understand that knowingly providing false information may expose me to civil or criminal penalties.

Respondent certifies that the information provided is true and complete.

I authorize the Company to verify the information and documents provided, including contacting governmental agencies or third parties as reasonably necessary to confirm identity or citizenship status.

Respondent authorizes verification as described above.

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