Legal Application Information Statement

LEGAL APPLICATION INFORMATION STATEMENT

This Legal Application Information Statement is made on this date: by and between Applicant Name: and Recipient Name: .

RECITALS

WHEREAS, Applicant has submitted or intends to submit an application described herein and requires a formal written statement of information to accompany such application; and

WHEREAS, Recipient requires accurate disclosures, certifications and authorizations from Applicant in order to process, evaluate, and retain records relating to the application; and

WHEREAS, the parties desire to record certain representations, consents and acknowledgements in connection with the application process.

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

1. DEFINITIONS

For purposes of this Statement, the following terms shall have the meanings set forth below: "Applicant" means the individual or entity identified as Applicant Name; "Recipient" means the entity identified as Recipient Name; "Application" means the submission for which this Statement is provided, including all supporting materials and subsequent amendments.

2. APPLICANT INFORMATION

Individual Corporation Partnership Trust Other:

3. APPLICATION DETAILS

4. SUPPORTING DOCUMENTS

Applicant submits with the Application the following materials (check all that apply and provide descriptions as indicated):

Filing fee paid Identification Corporate resolution / authority

5. CERTIFICATIONS AND REPRESENTATIONS

Applicant certifies and represents that the information provided in this Statement and any attachments is true, complete and accurate to the best of Applicant's knowledge. Applicant acknowledges that material misstatements or omissions may subject Applicant to penalties including denial of the Application and other legal remedies.

Applicant certifies accuracy of all statements and documents submitted.

If Applicant is an entity, the signer has full authority to bind the entity to this Statement and to the Application.

6. CONSENT TO RELEASE AND USE OF INFORMATION

Applicant hereby authorizes Recipient to verify and obtain information necessary to process the Application, including obtaining credit, criminal history, regulatory, or employment verifications where applicable and permitted by law. Applicant further authorizes third parties to release such information to Recipient upon request.

Applicant provides written consent for release of relevant records to Recipient as described above.

7. CONFIDENTIALITY

Recipient will treat information marked confidential in accordance with Recipient's policies and applicable law. Notwithstanding the foregoing, Recipient may disclose information where required by law, subpoena, or by court order or as necessary for the processing of the Application.

8. ACCURACY; FALSE STATEMENTS

Applicant acknowledges that knowingly submitting false information in connection with the Application may subject Applicant to civil and criminal penalties provided by law. Applicant agrees to promptly notify Recipient of any material changes to the information supplied herein.

9. NOTICES

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

10. AMENDMENTS; WAIVER

Any amendment to this Statement must be in writing and signed by both parties. No waiver of any breach shall be effective unless in writing and signed by the party granting the waiver.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Statement shall be governed by and construed in accordance with the laws of the jurisdiction in which the Recipient maintains its principal office, without regard to conflict of law principles. This Statement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings. If any provision of this Statement is determined to be invalid or unenforceable, such invalidity or unenforceability shall not affect the remaining provisions, which shall remain in full force and effect.

12. MISCELLANEOUS

This Statement 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. Signatures delivered by electronic means shall have the same force and effect as original signatures.

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