Legal Beneficial Owners Declaration

LEGAL BENEFICIAL OWNERS DECLARATION

This Legal Beneficial Owners Declaration (the "Declaration") is made on this day of , by and between Declarant: and Recipient: (each a "Party" and together the "Parties").

RECITALS

WHEREAS, Declarant is an entity organized under the laws of and carries on business under the registration number ; and

WHEREAS, applicable laws and regulatory standards require certain entities to identify and disclose individuals who are beneficial owners or who otherwise exercise control over the entity; and

WHEREAS, Recipient requires from Declarant a written declaration identifying all known beneficial owners and describing the nature and extent of each beneficial owner's interest or control for purposes of due diligence, compliance and recordkeeping.

NOW, THEREFORE, in consideration of the mutual covenants set forth herein and other good and valuable consideration, the Parties agree as follows:

1. DEFINITIONS

For purposes of this Declaration, the following terms have the meanings set forth below. "Beneficial Owner" means any individual who, directly or indirectly, (a) owns or controls, or (b) exercises substantial control over, the Declarant by virtue of ownership interest, voting power, contractual arrangements or other means, including persons who ultimately have a percentage ownership interest of 25% or more or who exercise significant influence or control by other means.

2. DECLARATION OF BENEFICIAL OWNERS

Declarant hereby provides the following information for each Beneficial Owner known to Declarant at the time of signing. Declarant represents that the information provided is complete and accurate to the best of Declarant's knowledge and belief.

Beneficial Owner 1

Beneficial Owner 2

Beneficial Owner 3 (if applicable)

3. CERTIFICATION AND REPRESENTATIONS

Declarant certifies, represents and warrants that: (a) the persons identified above are Beneficial Owners as defined herein or that Declarant has no Beneficial Owners to report; (b) all information provided in this Declaration and any attachments is true, complete and correct as of the date set forth above; and (c) Declarant will promptly notify Recipient in writing of any material change to the information provided herein.

Declarant understands that willful false statements or omissions made in this Declaration may subject Declarant and any individual signing on behalf of Declarant to civil or criminal penalties under applicable law, including penalties for fraud and perjury.

4. COLLECTION, USE AND RETENTION OF INFORMATION

Recipient may collect, retain and use the information provided in this Declaration and any supporting documentation to satisfy regulatory compliance obligations, to conduct due diligence and for purposes permitted by law. Recipient shall maintain reasonable administrative, technical and physical safeguards to protect the confidentiality of personal information consistent with its obligations under applicable law.

5. INDEMNITY

Declarant shall indemnify, defend and hold harmless Recipient and its affiliates, officers, directors and employees from and against any losses, liabilities, damages, costs or expenses (including reasonable attorneys' fees) arising from any breach of the representations or warranties made in this Declaration or from any material misstatement, omission or inaccuracy in the information provided.

6. NOTICES

Any notice required or permitted under this Declaration must be in writing and delivered to the addresses set forth below or to such other address as a Party may designate by notice in accordance with this section.

7. AMENDMENT; WAIVER; COUNTERPARTS

This Declaration may only be amended by a written instrument signed by both Parties. No failure or delay by either Party in exercising any right or remedy operates as a waiver of that right or remedy. This Declaration may be executed in counterparts, each of which will be an original and all of which together constitute one instrument.

8. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Declaration will be governed by and construed in accordance with the laws of the jurisdiction of without regard to its conflict of laws principles.

This Declaration constitutes the entire agreement between the Parties with respect to its subject matter and supersedes all prior agreements, understandings and communications, whether written or oral, regarding such subject matter. If any provision of this Declaration is held to be invalid or unenforceable, that provision will be enforced to the maximum extent permitted by law and the remaining provisions will remain in full force and effect.

9. CERTIFYING SIGNATORY AUTHORITY

The undersigned certifies that they are authorized to execute this Declaration on behalf of Declarant and that the information provided herein is true, correct and complete.

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