General Affidavit Waiver

GENERAL AFFIDAVIT WAIVER

This General Affidavit Waiver is made and entered into on this day of , by and between Affiant Name: residing at ("Affiant") and Recipient Name: with principal address ("Recipient").

RECITALS

WHEREAS, Affiant has knowledge of certain facts and circumstances relating to the matter described as: ; and

WHEREAS, Affiant desires to make a sworn statement of facts under oath and, in consideration of the mutual promises set forth herein, to irrevocably waive, release and discharge certain claims and causes of action as specified below;

WHEREAS, Recipient agrees to accept the Affidavit and Waiver subject to the terms and conditions contained in this instrument.

NOW, THEREFORE, in consideration of the mutual covenants and other good and valuable consideration, the sufficiency of which is acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, the following terms shall have the meanings set forth below:

"Claim" means any and all claims, actions, causes of action, suits, debts, liabilities, obligations, demands, losses, damages, costs, expenses, fines and penalties of any nature, whether known or unknown, foreseen or unforeseen, fixed or contingent, based on statute, tort, contract or otherwise.

"Released Parties" means Recipient and its past and present officers, directors, employees, agents, successors and assigns.

2. AFFIDAVIT OF FACTS

Affiant hereby certifies under oath and subject to penalty of perjury that the following statements are true and correct to the best of Affiant's knowledge, information and belief. Affiant declares and affirms the facts with particularity as follows:

Affiant acknowledges that the foregoing statements will be relied upon by Recipient and that any material misrepresentation or omission in the foregoing may give rise to legal claims, including claims for fraud and perjury, and shall constitute a breach of this Agreement.

3. WAIVER AND RELEASE

In consideration of the promises and undertakings set forth herein, Affiant, on behalf of Affiant and Affiant's heirs, executors, administrators, successors and assigns, hereby irrevocably and unconditionally waives, releases, relinquishes and forever discharges any and all Claims against the Released Parties arising out of, connected with, or related to the facts, occurrences or matters described in Section 2, including but not limited to claims for negligence, breach of contract, misrepresentation, and statutory claims.

This waiver and release extends to both known and unknown claims. To the extent permitted by law, Affiant expressly waives any rights under any statute or common law that would otherwise limit the scope of a general release of unknown claims.

4. REPRESENTATIONS AND WARRANTIES

Affiant represents and warrants that: (a) Affiant is over the age of eighteen and legally competent to execute this Affidavit Waiver; (b) Affiant has read and fully understands this document; (c) the facts set forth in Section 2 are true and correct; and (d) Affiant has not assigned, transferred or conveyed any right or interest in any Claim released by this Agreement.

5. INDEMNIFICATION

Affiant shall indemnify, defend and hold harmless the Released Parties from and against any and all liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees) incurred by reason of any breach of Affiant's representations, warranties or covenants set forth herein, or arising from any false, fraudulent or intentionally misleading statement or omission made by Affiant in connection with this Affidavit Waiver.

6. ACKNOWLEDGMENT OF VOLUNTARINESS

Affiant acknowledges that Affiant has had a reasonable opportunity to consult with independent counsel of Affiant's choosing, that Affiant understands the terms and legal effect of this Affidavit Waiver, and that Affiant executes this instrument voluntarily, without duress or undue influence.

7. NOTICES

All notices required or permitted under this Agreement shall be in writing and shall be deemed given when delivered personally, sent by certified mail with return receipt requested, or delivered by nationally recognized overnight courier, to the addresses set forth above or to such other address as either party may specify by notice in accordance with this Section.

8. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state specified above without regard to principles of conflicts of law. Each party consents to the exclusive jurisdiction and venue of the state and federal courts located therein for any dispute arising out of or relating to this Agreement.

9. ENTIRE AGREEMENT

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, negotiations, representations and understandings, whether written or oral. No other promises, statements or agreements shall be valid or binding unless in writing and executed by both parties.

10. SEVERABILITY

If any provision of this Agreement is held to be invalid, illegal or unenforceable by a court of competent jurisdiction, such provision shall be severed and the remaining provisions shall remain in full force and effect to the fullest extent permitted by law.

11. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment, modification or waiver of any provision of this Agreement shall be effective unless in writing and signed by both parties. No waiver of any breach shall constitute a waiver of any subsequent breach. This Agreement 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.

12. CERTIFICATION UNDER PENALTY OF PERJURY

Affiant certifies under penalty of perjury under the laws of the governing jurisdiction that the statements contained in this Affidavit are true and correct. Affiant understands that knowingly making a false statement on this Affidavit may subject Affiant to civil and criminal penalties.

NOTARY ACKNOWLEDGMENT

State of , County of .

On this day of , , before me personally appeared , proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed the same for the purposes therein contained.

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