Constitutional Fifth Amendment Form

CONSTITUTIONAL FIFTH AMENDMENT FORM

This Notice and Assertion of Privilege is made by Declarant Name: who affirms and invokes the privilege against self-incrimination guaranteed by the Fifth Amendment to the Constitution of the United States in connection with the matter captioned Case Caption: , Case Number: , before Court: . Date of this notice: .

RECITALS

WHEREAS, Declarant has been requested to provide testimony, statements, documents, or other information in the proceeding identified above; and

WHEREAS, Declarant reasonably believes that answering certain questions or producing certain materials may tend to incriminate Declarant or expose Declarant to criminal liability; and

WHEREAS, Declarant seeks to invoke and preserve all constitutional privileges including, but not limited to, the privilege against self-incrimination under the Fifth Amendment, and intends that such invocation not be construed as a waiver of any substantive or procedural rights.

NOW, THEREFORE

For good and valuable consideration, the sufficiency of which is acknowledged, Declarant and Counsel set forth the following assertion and procedures:

1. INVOCATION OF PRIVILEGE

Declarant hereby affirmatively invokes the Fifth Amendment privilege against self-incrimination and declines to answer, to provide testimony, or to produce any documents or communications to the extent that such testimony, answers, or materials would tend to incriminate Declarant or expose Declarant to criminal prosecution or penalty. The invocation applies to questions, requests, or demands arising in the identified proceeding and any related ancillary proceedings.

2. SCOPE OF ASSERTION

The privilege asserted covers: (a) testimonial communications; (b) compelled production of documents or things, to the extent production would be testimonial in nature; (c) responses to interrogatories, requests for admission, deposition questions, or viva voce testimony; and (d) any derivative use of compelled materials or testimony. Declarant does not waive the privilege by partially answering discrete questions not reasonably likely to elicit incriminating information.

3. SPECIFIC SUBJECTS AND PROCEEDINGS

Deposition Court Hearing Interrogatories Document Production Other

4. PROCEDURES AND NOTICE

Declarant or Declarant's counsel shall provide written notice of this invocation to opposing counsel, the court reporter, and the presiding judge, as appropriate. The notice shall identify the basis for invoking the privilege and shall identify any documents withheld or redacted. The provision of such notice is not, by itself, a waiver of the privilege.

5. NON-WAIVER AND LIMITED WAIVER

Declarant's assertion of the Fifth Amendment privilege is made in good faith and is not intended to constitute a voluntary waiver of any constitutional or statutory rights. Declarant expressly reserves the right to assert or withdraw the privilege as facts, circumstances, or rulings by a court may require. Any limited disclosure shall be construed narrowly and shall not constitute a general waiver of privilege, except to the extent required by a court order.

6. CERTIFICATION; PENALTIES

Declarant certifies under penalty of perjury under the laws of the United States and the applicable state law that the information provided in this form is true and correct to the best of Declarant's knowledge and that the invocation of the constitutional privilege is made on reasonable grounds. Declarant acknowledges that knowingly making a false statement in this document may subject Declarant to criminal penalties and sanctions.

7. NOTICES

8. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This assertion shall be governed by and construed in accordance with the laws of the jurisdiction in which the subject proceeding is pending. This form constitutes the complete written assertion and procedures agreed to by the parties identified herein with respect to the invocation of the Fifth Amendment privilege; no other prior or contemporaneous representations modify this assertion except by written amendment signed by the parties. If any provision of this form is held invalid or unenforceable, the remainder of the form shall remain in full force and effect.

9. AMENDMENTS; COUNTERPARTS

This form may be amended only by a written instrument signed by Declarant and Declarant's counsel or by order of the court. This form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

ADDITIONAL REPRESENTATIONS

Certification: I declare under penalty of perjury under the laws of the United States and under applicable state law that the foregoing is true and correct. I acknowledge that knowingly making a false statement may subject me to criminal prosecution and civil sanctions.

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