Legal Claimant Declaration

LEGAL CLAIMANT DECLARATION

This Legal Claimant Declaration is made on by Claimant Name: (hereinafter "Claimant"), and Respondent Name: (hereinafter "Respondent").

RECITALS

WHEREAS, Claimant asserts that Claimant has sustained loss, damage, or injury as a result of acts, omissions, transactions or occurrences described below; and

WHEREAS, Claimant seeks to declare the facts, identify relief sought, and submit supporting documentation in support of Claimant's claim against Respondent; and

WHEREAS, Claimant desires to make this Declaration under penalty of perjury and to certify the truth of the statements herein to the best of Claimant's knowledge, information, and belief.

NOW THEREFORE, in consideration of the mutual covenants and declarations contained herein, Claimant hereby declares and states as follows:

1. DEFINITIONS

For purposes of this Declaration, the following terms shall have the meanings set forth below: "Claim" means the asserted cause of action, demand for relief, or basis for compensation; "Supporting Documents" means records, invoices, receipts, photographs, correspondence, and other documentary evidence attached or referenced in support of the Claim.

2. DECLARATION OF FACTS

Date of Incident:    Time of Incident:

3. CLAIMED RELIEF AND DAMAGES

Claimant hereby states the relief sought as follows:

4. SUPPORTING DOCUMENTS

Claimant certifies that the following documents are attached or will be provided to substantiate the Claim (check all that apply):

Invoices or billing statements

Receipts or proof of payment

Photographs, diagrams, or video evidence

Correspondence or written notices

5. REPRESENTATIONS, WARRANTIES AND CERTIFICATION

Claimant represents and warrants that the statements set forth in this Declaration are true and correct to the best of Claimant's knowledge, information, and belief; that Claimant has provided all material information known to Claimant relevant to the Claim; and that Claimant understands that submitting false statements in this Declaration may subject Claimant to civil liabilities and criminal penalties under applicable law.

Claimant further certifies that Claimant is entitled to pursue the relief claimed and that no material facts have been intentionally omitted. Claimant agrees to produce upon reasonable request any additional documents or information necessary to substantiate the Claim.

6. NOTICES

All notices, demands, or other communications required or permitted under this Declaration shall be in writing and delivered to the addresses set forth below by hand, overnight carrier, or certified mail:

7. MISCELLANEOUS PROVISIONS

Governing Law: This Declaration shall be governed by and construed in accordance with the laws of the jurisdiction indicated below without regard to conflict of laws principles.

Entire Agreement: This Declaration, together with any attachments and supporting documents expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior statements and agreements, whether written or oral.

Severability: If any provision of this Declaration is held to be invalid or unenforceable, such provision shall be severed and the remaining provisions shall remain in full force and effect.

Amendments and Waiver: No amendment, modification or waiver of any provision of this Declaration shall be effective unless in writing and signed by both parties. The failure of either party to enforce any provision shall not constitute a waiver of any other provision.

Counterparts and Electronic Signatures: 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.

8. ACKNOWLEDGMENT AND SIGNATURE

UNDER PENALTY OF PERJURY, Claimant hereby declares that the foregoing statements are true and correct to the best of Claimant's knowledge and belief. Claimant understands that making a false statement in this Declaration may subject Claimant to civil and criminal penalties.

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