Client Eligibility Checklist

CLIENT ELIGIBILITY CHECKLIST

Client Name:    Client ID:

Date of Assessment:    Assessor Name:

RECITALS

WHEREAS, the Company provides professional services and programs for which eligibility must be verified prior to engagement; and

WHEREAS, the Client has requested evaluation of eligibility for the services described herein and affirmatively consents to provide documentation and attestations necessary for that evaluation;

WHEREAS, the parties intend to set forth the applicable criteria, documentation, and determination procedures by way of this checklist and accompanying certification.

SCOPE OF WORK

ELIGIBILITY CRITERIA

The assessor shall evaluate the Client against the following criteria. Check each applicable box and supply required supporting documentation.

1. Age requirement met (minimum age as required by program).    If checked, Date of Birth:

2. Residency / Jurisdiction requirement satisfied.    Address Verified:

3. Financial / income eligibility verified per program thresholds.    Supporting Document(s):

4. No disqualifying prior engagements, suspensions, or sanctions on record.    Notes:

5. Compliance history acceptable.    Evidence:

SUPPORTING DOCUMENTATION

Check documents provided and attach copies to the client file.

Government-issued identification

Proof of address

Income verification documents

DETERMINATION

After review of the above criteria and documentation, the assessor's determination (check one):

Eligible     Not Eligible     Conditional (see notes)

PAYMENT TERMS

The Client agrees to pay the Company for services provided as follows. Enter amounts and schedules below.

TERM AND TERMINATION

This checklist and any services authorized hereby commence on: and continue through: unless earlier terminated in accordance with this Agreement.

Either party may terminate this engagement for convenience upon written notice to the other party delivered not fewer than days prior to the intended termination date. Termination for cause may be immediate where the non-breaching party provides written notice specifying the breach and opportunity to cure where applicable.

CONFIDENTIALITY

Each party acknowledges that in connection with the performance of services and the eligibility review, it may receive Confidential Information of the other party. "Confidential Information" includes non-public business, financial, personal, program, and client data disclosed in written, electronic, or oral form. Recipients shall: (a) use Confidential Information solely for the purposes of evaluating eligibility and performing obligations hereunder; (b) restrict disclosure to employees or contractors with a need to know and subject to confidentiality obligations no less protective than those set forth herein; and (c) exercise at least the same degree of care in protecting Confidential Information as it uses to protect its own confidential materials, but in no event less than reasonable care. Confidential Information shall not include information that: (i) is or becomes publicly available without breach; (ii) is rightfully received from a third party without restriction; or (iii) is independently developed without use of the disclosing party's Confidential Information.

GOVERNING LAW; ENTIRE AGREEMENT

This Checklist and any agreement formed by relying upon its determinations shall be governed by the laws of the jurisdiction selected by the parties. Any disputes arising out of or relating to this Checklist shall be resolved under that governing law without regard to conflict of law principles. This Checklist constitutes the entire understanding between the parties with respect to the subject matter herein and supersedes all prior negotiations, representations, and agreements, whether written or oral, relating to the same.

CERTIFICATION

By signing below, the undersigned assessor certifies that the information recorded on this checklist is true, complete, and based on verifiable documentation. The Client certifies that the information and documentation provided are accurate to the best of the Client's knowledge and acknowledges that knowingly providing false information may result in denial of services and potential legal consequences.

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