Legal Background Declaration

LEGAL BACKGROUND DECLARATION

This Legal Background Declaration ("Declaration") is made as of Effective Date: by and between Declarant Name: , Declarant Address: and Receiving Party Name: , Receiving Party Address: .

RECITALS

WHEREAS, the Receiving Party has requested that Declarant disclose certain background information relevant to the Declarant's suitability for engagement, employment, licensure, contract performance, or other official relationship with the Receiving Party; and

WHEREAS, Declarant is willing to provide a truthful and complete declaration of such background information and to authorize the Receiving Party to verify the information as set forth below; and

WHEREAS, the parties intend that the Receiving Party may rely on the accuracy of the declarations and disclosures made herein in making determinations regarding the Declarant's qualifications and continued relationship with the Receiving Party.

NOW, THEREFORE

In consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, Declarant hereby declares, represents, warrants and agrees as follows:

1. DEFINITIONS

For purposes of this Declaration: "Background Information" means criminal convictions, pending criminal charges, civil litigation involvement, administrative proceedings, professional disciplinary actions, bankruptcy or insolvency filings, regulatory sanctions, and any other factual matters that would materially affect the Declarant's fitness for the role for which disclosure is sought. "Material" means reasonably likely to influence the Receiving Party's decision regarding engagement, retention, licensure, or continued relationship.

2. DECLARATIONS

Declarant affirms and answers the following items. For each item where Declarant indicates "Yes," Declarant shall provide a full explanation with dates, jurisdictions, case or file numbers if known, and current status in the corresponding response field.

(a) Have you been convicted of, pleaded guilty or nolo contendere to, or received a suspended imposition of sentence for any felony or misdemeanor? Yes No

(b) Are you currently a party to any civil litigation, arbitration, or administrative proceeding that could result in a material judgment or affect your ability to perform duties? Yes No

(c) Have you filed for bankruptcy, been adjudicated bankrupt, or been subject to an insolvency proceeding within the last ten years? Yes No

(d) Has any professional license or certification held by you been suspended, revoked, disciplined, or the subject of a pending investigation? Yes No

(e) Are you subject to any governmental, regulatory or international sanctions, watchlists, or enforcement actions that could materially affect your status? Yes No

3. REPRESENTATIONS AND WARRANTIES

Declarant represents and warrants that all Background Information provided in this Declaration is true, complete and correct to the best of Declarant's knowledge as of the Effective Date. Declarant covenants to promptly notify Receiving Party in writing of any material change in such Background Information that occurs after the Effective Date and during any period in which Declarant is engaged or considered for engagement by Receiving Party.

4. AUTHORIZATION TO VERIFY AND RELEASE

Declarant authorizes Receiving Party and its agents, representatives, or contractors to make inquiries, obtain records, and verify any information provided in this Declaration, including but not limited to criminal history, court records, employment history, credit or financial records to the extent permitted by law, and licensing or disciplinary records. Declarant releases from liability any person or entity providing such information in good faith.

5. CONFIDENTIALITY

Receiving Party shall treat Background Information obtained under this Declaration as confidential and shall not disclose such information except: (a) to its directors, officers, employees, counsel, auditors or agents with a need to know and who are bound to confidentiality; (b) as required by applicable law, regulation, subpoena, or court order; or (c) with Declarant's prior written consent. Notwithstanding the foregoing, Receiving Party may disclose to prospective insurers or regulatory authorities as reasonably necessary.

6. REMEDIES; INDEMNITY

In the event of any material misrepresentation, omission, or failure to disclose Background Information by Declarant, Receiving Party shall have the right to terminate any engagement, rescind offers, or take such other lawful action as appropriate. Declarant shall indemnify, defend and hold harmless Receiving Party from and against any losses, damages, liabilities, costs and expenses (including reasonable attorneys' fees) arising from any material misrepresentation or omission in this Declaration.

7. NOTICES

All notices required or permitted hereunder shall be in writing and delivered to the addresses below by certified mail, overnight courier, or personal delivery and shall be effective upon receipt.

8. AMENDMENTS; WAIVER; COUNTERPARTS

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

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Declaration shall be governed by and construed in accordance with the substantive laws of the governing jurisdiction chosen by the Receiving Party at the time of execution. This Declaration constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior written and oral agreements and understandings. If any provision of this Declaration is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

10. CERTIFICATION

By signing below, Declarant certifies under penalty of perjury under the laws of the governing jurisdiction that the information contained in this Declaration is true, correct and complete to the best of Declarant's knowledge and belief, and that Declarant understands that materially false statements may result in civil or criminal penalties and constitute grounds for termination or other adverse action by Receiving Party.

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