Legal Affidavit of Identity

LEGAL AFFIDAVIT OF IDENTITY

Affiant Name:   Affiant Address:

Date of Birth:   Place of Birth:   Affidavit Date:

Requesting Party Name:   Requesting Party Address:

RECITALS

WHEREAS, the Affiant, identified above, seeks to establish and certify his or her identity to the Requesting Party for the specific purpose of verification in connection with the Requesting Party's records and transactions; and

WHEREAS, the Requesting Party requires a sworn statement from the Affiant attesting to the Affiant's true name, date of birth, and identity documents presented in order to accept, rely upon, or retain copies of identity documentation; and

WHEREAS, the Affiant is competent to make this affidavit and does so voluntarily, under oath, and subject to penalty of perjury as provided by law.

NOW, THEREFORE

The Affiant hereby solemnly declares, affirms and certifies as follows:

1. DEFINITIONS

In this Affidavit, the terms "Affiant" and "Requesting Party" shall have the meanings set forth in the opening paragraph. "Identity Documents" means any government-issued or other documentary evidence of identity presented by the Affiant and described in Section 3 below.

2. AFFIANT STATEMENT OF IDENTITY

I, the Affiant named above, declare under penalty of perjury under the laws of the State of: that the following statements are true and correct:

(a) My full legal name is: ; and I have used no other legal name(s) except as disclosed herein.

(b) My date of birth is: and I reside at the address set forth above.

3. DOCUMENTS PRESENTED

The Affiant presented the following Identity Documents to the Requesting Party for inspection and copying. Check all that apply and supply details:

Driver's License   Number:   Issuing Authority:

Passport   Number:   Issuing Country:

Birth Certificate   Registrar:

Other   Describe:

Copies of the foregoing documents are attached to this Affidavit and shall be retained by the Requesting Party for its records.

4. AFFIRMATION, OATH AND PENALTY

I affirm under penalty of perjury that the statements contained in this Affidavit are true and correct, that the documents presented are genuine to the best of my knowledge and belief, and that I understand that knowingly making a false statement in this Affidavit may subject me to civil and criminal penalties under applicable law.

5. USE, RETENTION AND LIMITATION OF RELIANCE

The Requesting Party may rely upon this Affidavit and the attached document copies for the specific verification purpose described in the Recitals. The Requesting Party shall retain copies for its records and shall not use the Affidavit or attached documents for any purpose not reasonably related to the verification without the Affiant's express written consent, except as required by law.

6. REPRESENTATIONS, WARRANTIES AND INDEMNITY

The Affiant represents and warrants that the information provided in this Affidavit is true and correct. The Affiant agrees to indemnify and hold harmless the Requesting Party from and against any losses, claims, liabilities, expenses or damages arising out of any material misrepresentation or omission in this Affidavit.

7. NOTICES

Any notice required or permitted under this Affidavit shall be in writing and delivered to the addresses set forth above or to such other address as a party may designate by written notice. Notices shall be deemed given when received.

8. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Affidavit shall be governed by and construed in accordance with the laws of the State of: . This Affidavit constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior statements, understandings, or agreements. If any provision of this Affidavit is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

9. AMENDMENTS; WAIVER; COUNTERPARTS

This Affidavit may be amended only by a written document signed by both parties. No failure or delay by any party in exercising any right under this Affidavit shall operate as a waiver of that right. This Affidavit may be executed in counterparts and delivered by electronic means, each of which shall be an original and all of which together shall constitute one instrument.

10. ADDITIONAL DETAILS

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