Combined Affidavit Form

COMBINED AFFIDAVIT FORM

This Combined Affidavit Form is made and executed on this date by the parties identified below. Affiant Name: , Affiant Address: , Date of Birth: , Occupation:

Requesting Party Name: , Requesting Party Address: , Contact Representative:

RECITALS

WHEREAS, Affiant possesses certain factual knowledge and documentary records relating to matters identified herein and is willing to provide a sworn statement and copies of relevant records to the Requesting Party for legitimate business, legal or administrative purposes; and

WHEREAS, the Requesting Party requires a verified affidavit and supporting documentation to establish facts, claims or entitlement in connection with proceedings or internal review as described in this document; and

WHEREAS, the parties intend that this Combined Affidavit Form serve both as an affidavit of facts and as an authorization for the release and verification of specified records to the Requesting Party under the terms set forth below.

NOW THEREFORE, in consideration of the mutual covenants and representations set forth herein, the parties agree as follows:

1. DEFINITIONS

For the purposes of this Combined Affidavit Form, the following terms shall have the meanings set forth below: "Affiant" means the individual identified as affiant_name who is making the sworn statements; "Requesting Party" means the entity identified as requesting_party_name seeking verification or records; "Exhibits" means the documents described in Section 3 attached to or delivered with this Affidavit.

2. STATEMENT OF FACTS

The Affiant hereby states under oath the following facts, each of which the Affiant affirms to be true and correct to the best of the Affiant's knowledge and belief:

2.1 Transaction/Incident Description:

2.2 Relevant Date(s): Occurred on . The Affiant personally observed or has direct knowledge of the matters set forth herein as follows:

2.3 Detailed Statement:

3. EXHIBITS AND ATTACHMENTS

The Affiant attaches and delivers the following documents as Exhibits which are incorporated by reference and constitute material evidence supporting the statements above:

Exhibit A — Identifying Documentation (e.g., government-issued ID)
Exhibit B — Records (e.g., transactional, account, or correspondence records)
Exhibit C — Other supporting material

4. REPRESENTATIONS AND WARRANTIES

The Affiant represents and warrants that: (a) the facts set forth in Section 2 and any attached Exhibits are true, accurate and complete; (b) the Affiant has the authority and legal capacity to provide the records and statements described herein; and (c) no material fact has been knowingly omitted that would render the statements misleading.

5. OATH, VERIFICATION AND PENALTY

The Affiant declares under penalty of perjury under the laws of the State of that the foregoing statements and attached Exhibits are true and correct to the best of the Affiant's knowledge, information and belief. The Affiant acknowledges that a willful false statement made herein may subject the Affiant to criminal or civil penalties.

6. AUTHORIZATION TO RELEASE AND VERIFY RECORDS

The Affiant authorizes any person, entity or custodian of records identified in the Exhibits to release and verify the records described therein to the Requesting Party for purposes reasonably related to the matters set forth in this Affidavit. This authorization specifically includes:

Financial records
Employment records
Medical records (limited scope as permitted by law)
Other (describe below)

7. REMEDIES; INDEMNIFICATION

In the event of a material breach of the representations contained in this Affidavit or the making of a materially false statement, the Affiant shall be liable for damages and shall indemnify and hold harmless the Requesting Party from any losses, claims, liabilities, costs or expenses, including reasonable attorneys' fees, incurred as a result of such breach or false statement.

8. NOTICES

9. GOVERNING LAW; VENUE

This Combined Affidavit Form shall be governed by and construed in accordance with the laws of the State of . Any legal action arising out of or relating to this Affidavit shall be brought in the courts located within that State, and the parties submit to the exclusive jurisdiction of those courts.

10. ENTIRE AGREEMENT; SEVERABILITY; AMENDMENT; WAIVER; COUNTERPARTS

This Combined Affidavit Form, including any Exhibits attached hereto, constitutes the entire agreement between the parties with respect to the subject matter hereof. If any provision of this Affidavit is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Affidavit may be amended only by a written instrument executed by both parties. Failure by either party to enforce any provision shall not constitute a waiver of that provision. This Affidavit may be executed in counterparts, each of which shall be deemed an original.

11. ACKNOWLEDGMENTS

The parties acknowledge that they have read this Combined Affidavit Form, understand its contents, and have the authority to execute this Affidavit. Each party acknowledges receipt of a copy of this Affidavit.

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