Citizenship Verification Form

CITIZENSHIP VERIFICATION FORM

This Citizenship Verification Form (the "Form") is entered into as of by and between Requesting Entity Name: , with principal address , and Subject of Verification Name: , residing at .

RECITALS

WHEREAS, the Requesting Entity requires verification of the citizenship or immigration status of the Subject of Verification for purposes of compliance with applicable laws, eligibility determination, or other stated purposes; and

WHEREAS, the Subject of Verification is willing to provide documentary evidence and to consent to reasonable verification procedures by the Requesting Entity or its authorized agent; and

WHEREAS, the parties desire to set forth the terms, representations, consents and procedures governing the collection, verification, retention and permissible disclosure of citizenship-related information.

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. DEFINITIONS

For purposes of this Form, the following terms have the meanings set forth below: "Documentation" means passports, birth certificates, naturalization certificates, certificates of citizenship, resident permits, immigration documents, and other government-issued identification evidencing citizenship or immigration status. "Verification" means the review, authentication, and, if applicable, confirmation of Documentation against available records and databases.

2. SUBJECT INFORMATION

U.S. Citizen Naturalized Citizen Lawful Permanent Resident Dual Citizen Non-citizen

3. DOCUMENTS PROVIDED

The Subject hereby submits the following Documentation to the Requesting Entity for Verification. For each item submitted, list the issuing authority, document number and expiration date (if applicable).

4. AUTHORIZATION AND CONSENT

The Subject hereby authorizes the Requesting Entity, and its authorized agents and representatives, to review, copy, and verify the submitted Documentation and to contact issuing authorities, record holders, and other third parties as reasonably necessary to confirm the authenticity and current status of citizenship or immigration documentation. This authorization includes verification against governmental and non-governmental databases where permitted by law.

The Subject acknowledges that the Requesting Entity may rely upon information obtained from third-party sources and that such reliance shall not constitute a representation or warranty by the Requesting Entity of the accuracy of third-party records beyond reasonable verification procedures.

5. REPRESENTATIONS AND WARRANTIES

The Subject represents and warrants that: (a) all Documentation submitted is true, accurate and unaltered; (b) the Subject is the lawful holder of the Documentation and is authorized to permit its use for Verification; and (c) there are no pending proceedings known to the Subject that would materially alter the Subject's citizenship or immigration status that are not disclosed to the Requesting Entity.

The Requesting Entity represents and warrants that it will use the information obtained through Verification only for the purposes stated in this Form and in accordance with applicable law.

6. USE, RETENTION AND DESTRUCTION

The Requesting Entity shall store Documentation and Verification results in a secure manner and shall retain such records only for the period reasonably necessary to accomplish the stated purpose or as required by law. Thereafter, the Requesting Entity shall destroy or redact such records in a manner designed to protect the Subject's personal information from unauthorized access, except where retention is required by law or is otherwise permitted by the Subject in writing.

7. CONFIDENTIALITY; DISCLOSURE

Except as required by law or as necessary to effectuate Verification, the Requesting Entity shall maintain the confidentiality of the Subject's Documentation and shall not disclose confidential information to third parties without the Subject's prior written consent. Permitted disclosures may include disclosure to auditors, legal counsel, governmental authorities where mandated, and entities engaged to perform Verification services under a confidentiality obligation.

8. FALSE STATEMENTS; REMEDIES

The Subject acknowledges that knowingly providing false, forged, or materially misleading Documentation or statements in connection with this Form may constitute a violation of law and may subject the Subject to civil and criminal penalties and administrative sanctions. The Requesting Entity retains the right to terminate any relationship with the Subject and to pursue any available legal or equitable remedies for misrepresentation or fraud.

9. INDEMNIFICATION

The Subject shall indemnify, defend and hold harmless the Requesting Entity and its officers, directors, agents and employees from and against any claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees) arising from the Subject's breach of any representation, warranty or obligation under this Form, or from any negligent or willful misrepresentation by the Subject.

10. NOTICES

All notices required or permitted under this Form shall be in writing and shall be deemed given when delivered in person, sent by certified mail, return receipt requested, or delivered by nationally recognized overnight courier, to the addresses provided in the opening paragraph or to such other address as a party may designate in writing pursuant to this Section.

11. GOVERNING LAW

This Form shall be governed by and construed in accordance with the substantive laws of the state or jurisdiction of the Requesting Entity's principal place of business, without regard to conflict of laws principles. The parties submit to the exclusive jurisdiction of the state and federal courts located within such jurisdiction for purposes of any action arising under or relating to this Form.

12. 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, understandings and communications, whether written or oral, relating to such subject matter.

13. SEVERABILITY

If any provision of this Form is held invalid, illegal or unenforceable in any jurisdiction, the remaining provisions shall continue in full force and effect and the invalid provision shall be reformed to the extent necessary to make it enforceable while preserving the parties' intent.

14. AMENDMENT; WAIVER; COUNTERPARTS

No amendment or waiver of any provision of this Form will be effective unless made in writing and signed by both parties. Failure to exercise any right will not constitute a waiver of that right. 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.

15. CERTIFICATION BY SUBJECT

By signing below, the Subject certifies under penalty of perjury that the information and Documentation provided are true, complete and correct to the best of the Subject's knowledge and belief, and that the Subject consents to the Verification as set forth in this Form.

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