Debtor Identity Verification Form

DEBTOR IDENTITY VERIFICATION FORM

This Debtor Identity Verification Form is made effective as of by and between Creditor Name: with Principal Address: (hereinafter "Verifier") and Debtor Name: of Current Address: (hereinafter "Debtor").

RECITALS

WHEREAS, Verifier is engaged in the collection, management or administration of certain financial obligations and requires verified identity information to establish or confirm Debtor's legal identity and to comply with internal verification protocols; and

WHEREAS, Debtor has provided certain identifying information and documentary proof to Verifier and seeks to certify the accuracy of that information to permit Verifier to continue account management, billing, or other related actions; and

WHEREAS, the parties desire to set forth the nature of the information provided, the scope of authorization for verification, and the respective certifications and releases associated with such verification.

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

1. IDENTIFICATION OF DEBTOR

1.1 Full Legal Name:

1.2 Known Aliases or Former Names (if any):

1.3 Date of Birth:   Place of Birth:

1.4 Social Security Number (last four digits only):

1.5 Government-Issued Identification Presented: Driver's License State ID Card Passport Other

ID Issuing Authority:   ID Number:

Issue Date:   Expiration Date:

2. ADDRESS HISTORY

3. DOCUMENTS PROVIDED

Debtor represents that the following documents have been presented to Verifier for review and copying (if applicable):

Proof of government-issued photo identification
Proof of current address (utility bill, bank statement)
Birth certificate
Other documents

4. AUTHORIZATION TO VERIFY

Debtor hereby authorizes Verifier and its authorized agents to access, inspect, and verify the identity information and documentation provided, including but not limited to governmental records, motor vehicle records, passport databases, credit and address verification services, and other legitimate sources for the sole purposes of confirming identity and as necessary for the lawful administration of the account identified by the parties. This authorization continues until revoked in writing and does not authorize the procurement of new consumer reports for purposes other than identity verification related to the subject account.

5. CERTIFICATIONS AND REPRESENTATIONS

Debtor certifies under penalty of perjury that the information and documents provided to Verifier are true, correct and complete to the best of Debtor's knowledge. Debtor acknowledges that a material misrepresentation or omission may subject Debtor to civil or criminal penalties available under applicable law and may be grounds for adverse action by Verifier, including but not limited to cessation of account services or referral to collection or legal proceedings.

Verifier represents that it will use reasonable procedures to verify the authenticity of documents presented and will limit dissemination of the Debtor's identifying information to those employees, agents, or service providers with a legitimate need to know for verification and account administration. Verifier shall not be liable for any inaccuracy that results from Debtor's failure to provide current or accurate information.

6. RELEASE AND LIMITATION OF LIABILITY

Debtor releases Verifier, its employees and agents from liability for damages arising solely from Verifier's good-faith reliance on the documentation and information provided by Debtor, except to the extent caused by Verifier's gross negligence or willful misconduct. This release is limited to claims related to identity verification and does not affect Debtor's rights under applicable privacy or consumer protection laws.

7. DATA RETENTION AND CONFIDENTIALITY

Verifier may retain copies of identity documents and verification results for the period necessary to satisfy legal, regulatory, and business recordkeeping requirements. Debtor's information will be stored securely and access will be limited to personnel with a demonstrated need. Verifier will dispose of retained records in a manner intended to prevent unauthorized access when retention is no longer required.

8. NOTICES

All notices required or permitted under this Form shall be in writing and delivered to the addresses set forth below or to such other address as a party may designate by written notice to the other party in accordance with this Section.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Form shall be governed by and construed in accordance with the internal laws of the jurisdiction selected by Verifier for the account administration where not preempted by controlling law. This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations and understandings of the parties. If any provision of this Form is held to be invalid, illegal or unenforceable, the remainder of the provisions shall continue in full force and effect.

10. AMENDMENT; WAIVER; COUNTERPARTS

No amendment, modification or waiver of any provision of this Form shall be effective unless in writing and signed by both parties. A waiver by either party of any breach or default shall not be deemed a waiver of any subsequent breach or default. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

11. ACKNOWLEDGMENT

By signing below, Debtor acknowledges receipt of a copy of this Form, affirms that the information and documents provided are true and accurate, and grants the authorizations set forth herein. Verifier acknowledges receipt of the documentation described above and attests that the documents were reviewed in connection with identity verification.

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