Client Certification Questionnaire

CLIENT CERTIFICATION QUESTIONNAIRE

Client Name:    Service Provider Name:

WHEREAS

WHEREAS, Client Name is engaging Service Provider Name to perform certain services and to provide information necessary for regulatory, contractual and internal compliance review; and

WHEREAS, Service Provider Name requires representations and certifications from Client Name to confirm identity, beneficial ownership, tax classification, conflicts and other matters material to the provision of services described below; and

WHEREAS, the parties intend for this Questionnaire and the statements, certifications and disclosures herein to be relied upon by Service Provider Name in assessing suitability, compliance and the parties' contractual obligations.

SCOPE OF WORK

PAYMENT TERMS

Fee Amount:

Late Payment Fee:    Interest will accrue on late sums at the rate stated above and recoverable collection costs may apply.

TERM AND TERMINATION

Term Commencement:

Term Expiration:

Termination on Notice: Either party may terminate this engagement upon written notice delivered not less than days prior to the intended termination date.

Termination for Cause: Either party may terminate immediately for material breach, insolvency, or violation of applicable law.

CONFIDENTIALITY

Each party agrees to hold in confidence all non-public information disclosed in connection with this engagement, to use such information solely for the performance or receipt of services contemplated herein, and not to disclose such information except to its employees, agents or permitted advisors who have a need to know and are bound by confidentiality obligations no less protective than those herein. Confidentiality obligations shall survive termination for a period of years, except to the extent disclosure is required by law.

GOVERNING LAW

This Questionnaire, and any agreement arising from it, shall be governed by and construed in accordance with the laws of without regard to conflict of laws principles.

ENTIRE AGREEMENT

This Questionnaire, together with any engagement or service agreement executed by the parties, constitutes the entire agreement and understanding between the parties with respect to the matters contained herein and supersedes all prior and contemporaneous agreements, understandings, negotiations and representations, whether oral or written.

CLIENT IDENTIFICATION & CERTIFICATIONS

Individual    Corporation    Partnership    Limited Liability Company    Other:

Conflicts of Interest: No conflicts of interest to report. If there are conflicts, describe below.

Sanctions / Watchlists: Client and beneficial owners are not subject to economic or trade sanctions or watchlists. If checked, Client affirms no sanctions exposure.

Anti-Money Laundering Compliance: Client represents that it will comply with applicable anti-money laundering laws and has provided, or will promptly provide, any requested identification or verification documentation.

STATUTORY CERTIFICATIONS AND ATTESTATIONS

By checking each box below, Client certifies, represents and warrants to Service Provider Name that the corresponding statement is true and accurate as of the date of signature:

The information provided in this Questionnaire is true, complete and correct to the best of my knowledge and belief.

I am authorized to execute this Questionnaire on behalf of the Client and to bind the Client to its statements and obligations.

There are no pending or threatened material litigation or regulatory actions against the Client that would materially impede performance of services, except as disclosed in the Additional Remarks below.

CERTIFICATION

The undersigned certifies under penalty of perjury and other applicable penalties that the statements made in this Questionnaire are true and complete. The undersigned acknowledges that Service Provider Name will rely on these statements in deciding whether to enter into or continue the engagement described above and in discharging its compliance obligations.

Sign Now