Debtor Certification Form

Debtor Certification Form

This Debtor Certification Form (the "Certification") is executed on Day: Month: Year: by and between Debtor Name: of Debtor Address: and Creditor/Servicer Name: of Creditor Address: .

Recitals

WHEREAS, Creditor asserts that Debtor owes a sum arising under account or obligation identified below; and

WHEREAS, Creditor requires a sworn certification from Debtor of the accuracy of account information, current balance, and any disputes or defenses; and

WHEREAS, Debtor agrees to provide this Certification to facilitate account reconciliation, potential collection, or servicing actions.

NOW THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, Debtor and Creditor agree as follows:

1. Account Identification and Certification

1.1 Account Number:

1.2 Outstanding Balance: $

1.3 Date of Last Payment: Month: Day: Year:

1.4 Debtor certifies, under penalty of perjury and to the best of Debtor's knowledge, that the information provided in this Certification is true, accurate and complete, including the amount of the outstanding balance, the identity of the obligor(s), and the dates stated above.

2. Debtor Representations and Disclosures

2.1 Entity Type (check all that apply):
Individual   Corporation   Partnership   Other

2.2 Debtor affirms that, except as disclosed in Section 2.3 below, Debtor has no known legal defenses, counterclaims or setoffs with respect to the identified obligation. Debtor acknowledges that any material misstatement may subject Debtor to civil and criminal penalties.

3. Authorization and Consent

3.1 Debtor authorizes Creditor and its agents to obtain and verify credit, employment, bank account, and other financial records as reasonably necessary to confirm the statements made herein and to pursue collection, reconciliation, or servicing of the account.

3.2 Debtor expressly consents to electronic or written communications from Creditor for purposes of notice, collection, and account administration at the contact information provided below.

4. Remedies and Acknowledgements

4.1 Debtor acknowledges that Creditor may rely on this Certification in determining collection or servicing activities, including litigation, credit reporting, settlement negotiations, or account resolution.

4.2 If Debtor knowingly provides false or misleading information, Creditor may pursue all available remedies, including but not limited to recovery of costs, attorneys' fees, and any statutory damages permitted by applicable law.

5. Notices

All notices required or permitted under this Certification shall be in writing and addressed as follows (or to such other address as a party may designate in writing):

6. Miscellaneous Provisions

Governing Law: This Certification shall be governed by and construed in accordance with the laws of the state specified below without regard to conflicts of law principles. The parties consent to the exclusive jurisdiction of the courts located in the selected jurisdiction for any dispute arising under this Certification.

Choice of Law State:

Entire Agreement: This Certification constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether written or oral.

Severability: If any provision of this Certification is determined to be invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not be affected or impaired thereby.

Amendments; Waiver: No amendment, modification, or waiver of any provision of this Certification shall be effective unless in writing and signed by both parties. No failure or delay by either party in exercising any right shall operate as a waiver of that right.

Counterparts: This Certification may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument.

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