Legal Application Withdrawal Form

Legal Application Withdrawal Form

This Legal Application Withdrawal Form is made and entered into as of by and between Applicant Name: (the "Applicant") and Recipient Name: (the "Recipient").

RECITALS

WHEREAS, Applicant submitted an application identified as Application ID: for Application Type: to Recipient on Submission Date: .

WHEREAS, Applicant desires to withdraw the application in whole and to have the withdrawal reflected in Recipient's records in accordance with the terms set forth in this form.

WHEREAS, Recipient is willing to accept the withdrawal subject to the conditions, representations, and indemnities set forth in this document.

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

1. Withdrawal; Effect of Withdrawal

1.1 Withdrawal. Applicant hereby irrevocably withdraws the application identified above effective as of Effective Withdrawal Date: (the "Withdrawal Date"). Upon the Withdrawal Date, Recipient shall cease all processing, review, or consideration of the withdrawn application, except to the extent necessary to effectuate the withdrawal in accordance with this form.

1.2 Consequences. The withdrawal shall not constitute an admission of liability or fault by either party. Withdrawal does not extinguish obligations that accrued prior to the Withdrawal Date unless expressly set forth in this form.

2. Representations and Warranties

2.1 Applicant Representations. Applicant represents and warrants that Applicant is the lawful party entitled to withdraw the application, that the information provided in the application and in this form is true and complete to the best of Applicant's knowledge, and that no assignment, lien, or encumbrance exists that would prevent Applicant from effecting this withdrawal.

2.2 Recipient Representations. Recipient represents that it will process the withdrawal in accordance with its internal procedures and applicable law and will provide confirmation of the withdrawal as set forth in Section 5 if requested.

3. Release and Indemnity

3.1 Release. Except as provided in this form, Applicant releases Recipient, and each of Recipient's officers, directors, employees, agents and representatives, from any and all claims, demands, causes of action, liabilities and damages arising out of or related to the withdrawn application from the beginning of time through the Withdrawal Date, except claims arising from Recipient's willful misconduct or gross negligence.

3.2 Indemnity. Applicant shall indemnify, defend and hold harmless Recipient from and against any and all losses, liabilities, costs and expenses (including reasonable attorneys' fees) arising out of any third-party claim related to Applicant's withdrawal, except to the extent such claim arises from Recipient's willful misconduct or gross negligence.

4. Confidentiality and Records

4.1 Confidential Information. The parties shall continue to treat all confidential information exchanged in connection with the application in accordance with any existing confidentiality obligations. Withdrawal does not authorize the public disclosure of confidential materials unless otherwise required by law.

5. Fees and Refunds

5.1 Fees. Any fees paid in connection with the application shall be handled in accordance with Recipient's fee policies unless otherwise agreed in writing. Applicant requests refund consideration as indicated below.

6. Notices

6.1 Method. Any notice required or permitted under this form shall be in writing and delivered by personal delivery, certified mail, or overnight courier to the addresses set forth below or to such other address as either party may designate in writing.

7. Amendments; Waiver; Counterparts

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

7.2 Counterparts. This form 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 be effective as originals.

8. Governing Law; Entire Agreement; Severability

8.1 Governing Law. This form shall be governed by and construed in accordance with the laws of the State of without regard to principles of conflict of laws.

8.2 Entire Agreement. This form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals and understandings, whether written or oral, relating to the withdrawal of the application.

8.3 Severability. If any provision of this form is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect to the maximum extent permitted by law.

9. Additional Provisions

9.1 Authority. Each person signing this form represents and warrants that he or she has full authority to execute this form on behalf of the party for which he or she signs.

9.2 Expenses. Except as otherwise provided herein, each party shall bear its own costs and expenses in connection with the preparation, negotiation and execution of this form.

CERTIFICATION

Applicant certifies under penalty of perjury that the information contained in this withdrawal form is true, accurate and complete, and that Applicant is authorized to request and execute the withdrawal described herein.

AUTHORIZATION OF REPRESENTATIVE (IF APPLICABLE)

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