Client Status Questionnaire

CLIENT STATUS QUESTIONNAIRE

RECITALS

This Client Status Questionnaire (the "Questionnaire") is provided in connection with the business relationship between: Client Name: and Service Provider Name: .

WHEREAS, the Service Provider requires certain factual, financial and compliance information from the Client to establish, maintain or modify the engagement; and

WHEREAS, the Client agrees to furnish accurate, complete and timely responses to the items set forth below and to update this Questionnaire as required by the Service Provider's policies and applicable law.

CLIENT IDENTIFICATION

Individual Corporation Limited Liability Company Partnership Trust

BUSINESS STATUS & OPERATIONS

Current operational status: Active Inactive Dissolved Pending restructuring or sale

SCOPE OF WORK

Describe the services, deliverables and responsibilities to be performed by the Service Provider under the engagement. Include milestones, acceptance criteria, and any deliverable-specific information.

PAYMENT TERMS

Agreed compensation: $ payable pursuant to the schedule below.

Late payment fee: . The Client shall pay all reasonable collection costs and interest as set forth above on overdue balances.

TERM AND TERMINATION

Engagement start date: . Intended end date or review date: .

Either party may terminate this engagement for convenience upon days' prior written notice. Termination for cause is permitted immediately upon material breach that remains uncured after ten (10) days' written notice, or sooner where law requires.

CONFIDENTIALITY

The Client and the Service Provider each acknowledge that in the course of the engagement they may receive Confidential Information (as defined below). "Confidential Information" means non-public information disclosed in any form that is designated confidential or that a reasonable person would understand to be confidential. Each party shall (i) use Confidential Information solely to perform its obligations under this engagement; (ii) restrict disclosure to those employees, agents or permitted subcontractors with a need to know and who are bound by confidentiality obligations at least as protective as those herein; and (iii) protect Confidential Information with at least the same degree of care it uses to protect its own confidential information, but in no event less than reasonable care.

Exceptions: Confidential Information does not include information that is (a) in the public domain through no breach by the receiving party; (b) rightfully known to the receiving party prior to disclosure; (c) rightfully obtained from a third party without restriction; or (d) independently developed without use of the disclosing party's Confidential Information. Disclosure required by law or regulation shall be subject to advance notice to the disclosing party where permitted.

COMPLIANCE, REPRESENTATIONS & RISK

The Client represents and warrants that the information provided in this Questionnaire is true, complete and correct to the best of the Client's knowledge. The Client shall promptly notify the Service Provider in writing of any material change to the information contained herein.

Please indicate the following adverse status items by checking Yes or No and providing brief details where requested.

1. Has the Client or any owner/beneficial owner been subject to bankruptcy, insolvency, or receivership within the last 10 years? Yes No

2. Is the Client or any beneficial owner a politically exposed person (PEP) or a close associate of a PEP? Yes No

3. Within the last five (5) years, has the Client been subject to any regulatory enforcement, criminal investigation, or material litigation that could affect this engagement? Yes No

GOVERNING LAW

This Questionnaire, and any dispute arising hereunder, shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of laws principles.

ENTIRE AGREEMENT; SEVERABILITY

The terms set forth in this Questionnaire, together with any related engagement letter or service agreement, constitute the entire agreement between the parties with respect to the subjects addressed herein and supersede all prior statements and understandings, whether written or oral, relating to those subjects. If any provision of this Questionnaire is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

ACKNOWLEDGMENT AND CERTIFICATION

The undersigned certifies, on behalf of the Client, that the information provided in this Questionnaire is true, complete and correct, and that the undersigned is authorized to provide this information and to bind the Client to the certifications and representations contained herein.

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