Legal Authority Receive Form

LEGAL AUTHORITY RECEIVE FORM

This Legal Authority Receive Form is made effective as of Effective Date: by and between Principal Name: with principal address: ("Principal") and Authorized Recipient Name: with address: ("Agent").

Recitals

WHEREAS, Principal possesses certain rights, records, property, or interests described herein that may require receipt or acceptance by an authorized third party; and

WHEREAS, Principal desires to appoint Agent to receive on Principal's behalf specified legal documents, notices, correspondence, funds, or similar items as set forth in this Form; and

WHEREAS, Agent is willing to accept such appointment and to act in accordance with the terms and limitations set forth herein.

NOW, THEREFORE

In consideration of the mutual covenants contained in this Form, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. Appointment; Scope of Authority

1.1 Appointment. Principal hereby appoints Agent, and Agent accepts appointment, as Principal's authorized recipient to receive the types of items checked below on behalf of Principal. Acceptance by Agent constitutes authority for Agent to take custody of and acknowledge receipt of such items to the extent reasonably necessary to effectuate delivery.

1.2 Authority Selection (check all that apply):

Receive service of process and other litigation-related papers

Receive legal notices, correspondence, and administrative communications

Receive funds, checks, or other monetary instruments

Receive contracts, agreements, deeds, titles, or other legal documents

Other:

2. Limitations; Conditions

2.1 Limitations. Agent's authority is limited strictly to receipt and acknowledgement of the items specified in Section 1.2 and does not include authority to negotiate, endorse, transfer, alter, dispose of, or otherwise bind Principal with respect to funds or property unless expressly indicated in writing below.

2.2 Conditions Precedent. Agent shall not exercise any authority granted herein until Agent provides to Principal a signed acceptance of appointment and any documentation reasonably requested by Principal to verify Agent's identity and capacity.

3. Term; Termination; Revocation

3.1 Term. This appointment shall commence on the Effective Date set forth above and shall continue until Termination Date: unless earlier terminated in accordance with this Section.

3.2 Revocation. Principal may revoke this appointment at any time by giving written notice to Agent in accordance with the Notices provision below. Revocation is effective upon actual receipt of such notice by Agent.

4. Representations and Warranties

4.1 Principal represents and warrants that Principal has full legal capacity and authority to grant the appointment set forth herein and that acceptance of the authority by Agent will not violate any agreement, statute, judgment, or order to which Principal is subject.

4.2 Agent represents and warrants that Agent will exercise the authority conferred herein in good faith, in a commercially reasonable manner, and solely for the purposes authorized by Principal and in compliance with applicable law.

5. Indemnity and Liability

5.1 Indemnity. To the fullest extent permitted by law, Principal shall indemnify, defend, and hold harmless Agent from and against any and all claims, liabilities, losses, damages, costs, and expenses (including reasonable attorneys' fees) arising out of or relating to Agent's good faith performance of the duties expressly set forth in this Form.

5.2 Limitation of Liability. Agent shall not be liable for any indirect, incidental, consequential, or punitive damages arising from the receipt of items hereunder, except to the extent caused by Agent's gross negligence or willful misconduct.

6. Confidentiality

Agent shall keep confidential all non-public information received on behalf of Principal and shall not disclose such information to third parties except (a) with Principal's prior written consent, (b) as required by law, or (c) to the extent necessary to perform the duties contemplated by this Form.

7. Notices

All notices under this Form shall be in writing and delivered to the parties at the addresses set forth below (or to such other address as a party may specify by notice in accordance with this Section). Notice shall be effective upon actual receipt.

8. Amendments; Waiver; Counterparts

8.1 Amendment. This Form may be amended only by a written instrument signed by both parties.

8.2 Waiver. No waiver of any provision of this Form shall be effective unless in writing and signed by the waiving party. No waiver shall constitute a waiver of any other provision or any subsequent breach.

8.3 Counterparts. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

9. Governing Law; Entire Agreement; Severability

9.1 Governing Law. This Form shall be governed by and construed in accordance with the laws of the jurisdiction selected by the parties: Governing Jurisdiction: , without regard to its conflicts of law principles.

9.2 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 and understandings, whether written or oral.

9.3 Severability. If any provision of this Form is held to be invalid, illegal, or unenforceable, the remaining provisions shall continue in full force and effect and the parties shall negotiate in good faith to replace the invalid provision with a valid provision that most closely effects the original parties' intent.

10. Miscellaneous

10.1 Authority to Execute. Each party represents that the individual executing this Form on its behalf has the authority to bind the party to the terms of this Form.

Principal acknowledges that Principal has read and understands the rights and obligations created by this Form and confirms that the authority granted is limited to the scope and duration expressly set forth herein.

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