Legal Authority Claim

LEGAL AUTHORITY CLAIM

This Legal Authority Claim is made on this by Claimant Name: whose address is , against Respondent Name: , whose address is .

RECITALS

WHEREAS, Claimant asserts that Claimant possesses legal authority to act with respect to the subject matter described below, by virtue of documents, court order, statutory appointment, or corporate resolution; and

WHEREAS, Respondent receives notice that Claimant intends to assert such authority and that Claimant will provide copies of the documentary evidence supporting this claim; and

WHEREAS, the parties desire to record the asserted scope, basis, and limitations of the asserted authority in order to facilitate reliance and to allocate risk associated with any action taken in reliance on this Claim;

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

1. CLAIM OF AUTHORITY

1.1 Claimant asserts that Claimant holds the following capacity (check all that apply) and has authority as indicated:

Executor or Personal Representative    Administrator    Attorney-in-Fact (Power of Attorney)    Corporate Officer or Agent    Court-Appointed Fiduciary    Other

1.2 Subject matter of asserted authority (property, account, proceeding, matter):

2. BASIS AND SUPPORTING DOCUMENTS

2.1 Claimant states that the legal basis for the asserted authority is one or more of the following (check all that apply) and that certified or true copies of the referenced documents are attached or will be delivered upon request:

Last Will and Testament    Letters Testamentary or Letters of Administration    Power of Attorney (durable or limited)    Court Order    Corporate Resolution or Bylaws    Other

2.2 Claimant represents that the documents listed are true, accurate, unrevoked and, where required, duly certified or authenticated. Claimant agrees to furnish originals or certified copies upon reasonable request by Respondent or a court of competent jurisdiction.

3. SCOPE AND LIMITATIONS

3.1 The authority claimed herein extends only to the actions expressly described and to those reasonably necessary to effectuate those actions. This Claim does not, by itself, convey title, transfer property, or substitute for any required court approval unless expressly stated and accompanied by appropriate court order.

4. REPRESENTATIONS AND WARRANTIES

4.1 Claimant represents and warrants that: (a) the authority asserted is currently valid and has not been revoked, terminated or suspended; (b) there are no known conflicting claims of authority of which Claimant is aware; and (c) Claimant will promptly notify Respondent of any change in the status of the asserted authority.

5. INDEMNIFICATION

5.1 To the fullest extent permitted by law, Claimant shall indemnify, defend and hold harmless Respondent from and against any and all losses, liabilities, claims, costs and expenses (including reasonable attorneys' fees) arising from Respondent's good-faith reliance on this Claim, provided that such indemnity shall not apply to losses resulting from Respondent's gross negligence or willful misconduct.

6. NOTICE AND CONTACT

6.1 All notices, requests, and other communications required or permitted under this Claim shall be given in writing and delivered to the addresses or contacts set forth below. Delivery by ordinary mail, courier, or electronic mail (where acknowledged) shall be effective as provided by applicable law.

7. GOVERNING LAW; MISCELLANEOUS

7.1 Governing Law. This Claim shall be governed by and construed in accordance with the laws of the State of without regard to its choice-of-law rules.

7.2 Entire Agreement. This document constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous statements, understandings, or agreements, whether written or oral, concerning the same.

7.3 Severability. If any provision of this Claim is held invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect.

7.4 Amendments and Waiver. No amendment or waiver of any provision of this Claim shall be effective unless in writing and signed by both parties. No failure or delay in exercising any right under this Claim shall operate as a waiver of that right.

7.5 Counterparts. This Claim 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.

8. CERTIFICATION

Claimant certifies under penalty of perjury under the laws of the jurisdiction specified above that the information contained in this Claim and the attached documents is true, correct and complete to the best of Claimant's knowledge and belief.

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