Legal Beneficial Ownership Declaration

LEGAL BENEFICIAL OWNERSHIP DECLARATION

This Legal Beneficial Ownership Declaration (the Declaration) is made as of by and between Company Name: (the "Company") and Declarant Name: (the "Declarant").

RECITALS

WHEREAS, the Company is a juridical person organized under the laws of and is required to identify and document persons who are beneficial owners or controllers of the Company; and

WHEREAS, the Declarant is an individual or authorized representative who has knowledge of the Company's ownership and control and is authorized to make the representations, disclosures and certifications contained in this Declaration; and

WHEREAS, the parties desire to record the identity, ownership percentage and control information for persons who meet the definition of Beneficial Owner for the purposes of applicable laws and internal compliance procedures.

NOW, THEREFORE

In consideration of the mutual covenants set forth herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties hereby agree as follows:

1. DEFINITIONS

For purposes of this Declaration, the following terms shall have the meanings set forth below:

"Beneficial Owner" means an individual who, directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise: (a) exercises substantial control over the Company; or (b) owns or controls, directly or indirectly, 25% or more of the ownership interests of the Company. Determinations of control and ownership shall be made in accordance with applicable law and customary compliance standards.

2. COMPANY INFORMATION

Corporation Limited Liability Company Partnership Other:

3. IDENTIFICATION OF BENEFICIAL OWNERS

The Declarant certifies that the following individuals are Beneficial Owners or substantial controllers of the Company. For each listed person, provide the requested information.

Beneficial Owner 1

Direct ownership Indirect ownership Substantial control / officer

Beneficial Owner 2 (if applicable)

Direct ownership Indirect ownership Substantial control / officer

If additional Beneficial Owners exist, attach a signed schedule with equivalent fields and mark below:

4. CERTIFICATIONS AND REPRESENTATIONS

The Declarant hereby certifies, represents and warrants to the Company and its successors and assigns that:

(a) The information provided in this Declaration is true, complete and correct to the best of the Declarant's knowledge as of the Effective Date and accurately identifies each individual who is a Beneficial Owner or controller of the Company.

(b) The Declarant has the authority to disclose the information herein on behalf of the Company and will provide reasonable documentary evidence upon request to substantiate identity and ownership claims.

(c) The Declarant will promptly notify the Company in writing of any material change in the information provided in this Declaration, including any change to the identity or percentage ownership of any Beneficial Owner, within days of such change.

5. USE, CONFIDENTIALITY AND AUTHORIZED DISCLOSURE

The Company may use, retain and disclose the information provided in this Declaration to comply with applicable laws, regulatory requirements, and legitimate compliance, audit or investigative processes. The Company agrees to treat the information as confidential and to implement reasonable safeguards, except where disclosure is required by law, subpoena, court order, or regulatory request.

6. INDEMNITY AND REMEDIES

The Declarant agrees to indemnify and hold harmless the Company, its affiliates and their respective officers, directors and agents from and against any losses, claims, liabilities, damages or expenses (including reasonable attorney fees) arising from any materially false statement, omission or failure to update information in breach of the representations in this Declaration.

7. NOTICES

All notices, requests, demands and other communications under this Declaration shall be in writing and delivered to the addresses set forth below or to such other address as a party designates in writing in accordance with this Section.

8. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment to this Declaration shall be effective unless in writing and signed by both parties. Waiver of any provision or breach shall not be construed as a waiver of any other provision or subsequent breach. This Declaration may be executed in counterparts, each of which shall be an original and all of which together shall constitute one and the same instrument.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Declaration shall be governed by and construed in accordance with the laws of the jurisdiction of without regard to conflict of law principles. This Declaration constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings. If any provision of this Declaration is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

10. CERTIFICATION

By signing below, the Declarant and the Company each certify, under penalty of perjury to the extent permitted by applicable law, that the information contained in this Declaration is true, correct and complete, and that they each have the authority to provide and to receive the information contained herein. The parties acknowledge that civil and criminal penalties may result from knowingly providing false information.

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