Legal Consent and Declaration Form

LEGAL CONSENT AND DECLARATION FORM

This Legal Consent and Declaration Form (the "Agreement") is made effective as of by and between Client Name: , with primary address at , and Recipient Name: , with primary address at .

RECITALS

WHEREAS, Client Name desires to provide certain confidential information, statements or records concerning the matter described as: ;

WHEREAS, Recipient Name requires the written consent of Client Name to receive, use, process, or rely upon such information for the purposes set forth in this Agreement;

WHEREAS, the parties wish to record Client Name's consent, declarations and authorizations regarding disclosure, use, and retention of the information described above.

NOW, THEREFORE, in consideration of the mutual covenants and promises contained herein, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, "Confidential Information" means any non-public information, records, or statements, whether oral, written or electronic, provided by Client Name to Recipient Name concerning the subject matter, including but not limited to documents, identifiers, financial data, personnel records, and investigative reports.

2. CONSENT

Client Name hereby expressly consents to Recipient Name's receipt, collection, use, retention and limited disclosure of Confidential Information for the purpose of: .

Client Name further authorizes Recipient Name to obtain records from third parties and to disclose Confidential Information to its employees, agents, contractors, consultants or advisors who have a need to know for the stated purpose and who are bound by confidentiality obligations at least as protective as those herein.

3. DECLARATIONS AND REPRESENTATIONS

Client Name declares and represents that: (a) the information provided by Client Name is true and accurate to the best of Client Name's knowledge; (b) Client Name has full legal authority to execute this consent; and (c) no other person or entity holds an enforceable right that would prevent the disclosures authorized herein, except as disclosed in writing below:

4. AUTHORIZATION TO RELEASE INFORMATION

Client Name expressly authorizes any custodian or holder of records to release Confidential Information to Recipient Name, including but not limited to medical providers, financial institutions, government agencies, and educational institutions, in each case where such disclosure is reasonably necessary for the stated purpose.

5. CONFIDENTIALITY AND DATA USE

Recipient Name shall maintain Confidential Information in confidence and shall not disclose such information except as expressly authorized herein or as required by law. Recipient Name shall implement reasonable administrative, technical and physical safeguards to protect Confidential Information from unauthorized access, use or disclosure.

If Confidential Information is subject to statutory or regulatory protection, Recipient Name agrees to handle such information in accordance with applicable legal obligations and to notify Client Name promptly upon receipt of any request for disclosure by a third party or government authority.

6. RETENTION; REVOCATION

This authorization shall remain in effect until the earlier of (a) the date specified by Client Name below, or (b) written revocation delivered to Recipient Name; provided that revocation will not apply to disclosures already made in reliance on this authorization prior to receipt of revocation.

7. REPRESENTATIONS, INDEMNITY AND LIMITATION

Client Name represents that execution of this Agreement will not violate any other agreement. Client Name agrees to defend, indemnify and hold harmless Recipient Name from any claims, liabilities or losses arising from inaccurate or fraudulent statements provided by Client Name, except to the extent caused by Recipient Name's intentional misconduct or gross negligence.

8. NOTICES

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses provided below or such other address as a party may designate by written notice:

9. AMENDMENT; WAIVER

No amendment, modification or waiver of any provision of this Agreement shall be effective unless in writing and signed by both parties. Waiver of any breach shall not constitute a waiver of any subsequent breach.

10. GOVERNING LAW; VENUE

This Agreement shall be governed by and construed in accordance with the laws of the state indicated below, without regard to conflict of laws principles. The parties submit to the exclusive jurisdiction of the state and federal courts located in that state for resolution of disputes arising under this Agreement.

11. ENTIRE AGREEMENT; SEVERABILITY; COUNTERPARTS

This Agreement contains the entire understanding of the parties relating to the subject matter hereof and supersedes all prior agreements and understandings, oral or written. If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Agreement may be executed in counterparts and by electronic signature, each of which shall be deemed an original.

12. ADDITIONAL ACKNOWLEDGEMENTS

By signing below, Client Name acknowledges receipt of a copy of this Agreement, affirms understanding of the content, and confirms that Client Name's consent is given voluntarily and without coercion.

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