Legal Criminal Declaration Form

LEGAL CRIMINAL DECLARATION FORM

This Legal Criminal Declaration Form is executed on this day of , by Declarant Name: and Requesting Party Name: .

RECITALS

WHEREAS, the Requesting Party requires a sworn declaration regarding the Declarant's criminal history for the purpose of evaluating eligibility, licensure, employment, or placement with respect to duties identified by the Requesting Party; and

WHEREAS, the Declarant is competent to make this declaration, has personal knowledge of the facts stated herein, and acknowledges that this declaration will be relied upon by the Requesting Party in making determinations that may affect the Declarant's status; and

WHEREAS, the parties desire to set forth the full and complete criminal history disclosure of the Declarant and to provide authorization for the limited use of this information as set forth below.

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the sufficiency of which is acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Declaration: (a) "Conviction" means any plea of guilty, plea of nolo contendere, verdict of guilty, or adjudication of delinquency or guilt by a court of competent jurisdiction; (b) "Disposition" means the final outcome of a charge, including dismissal, conviction, acquittal, deferred adjudication, expungement, or sealing; and (c) "Criminal History" means all arrests, charges, convictions, diversions, deferred adjudications, and juvenile adjudications that are not expressly sealed or legally expunged.

2. DECLARANT IDENTIFICATION

DOB: / /

3. STATEMENT OF CRIMINAL HISTORY

The Declarant certifies under penalty of perjury that the following statements accurately describe the Declarant's criminal history. The Declarant must either (a) check the box below indicating no reportable criminal history, or (b) fully disclose each matter using the provided fields and attach certified dispositions if available.

I affirm that I have no convictions, pending criminal charges, or adjudications to disclose that are reportable under applicable law.

If you have reportable criminal history, list each matter below. Provide additional pages if necessary.

Date of Arrest/Charge:    Jurisdiction:    Disposition:

Date of Arrest/Charge:    Jurisdiction:    Disposition:

4. AUTHORIZATION AND CONSENT

The Declarant hereby authorizes the Requesting Party and its designated agents to obtain, review, and rely upon any criminal records, court dispositions, and similar reports necessary to verify the statements made in this Declaration. The Declarant acknowledges that such information may include arrests, charges, convictions, diversions, and juvenile adjudications where not legally sealed, and consents to the limited use of such information for the purpose stated herein.

5. CERTIFICATION

The Declarant certifies under penalty of perjury under the laws of the governing jurisdiction that the foregoing is true and correct to the best of the Declarant's knowledge and belief. The Declarant understands that knowingly making a false statement in this Declaration may result in civil and criminal penalties, including but not limited to perjury charges, and may be grounds for denial of application, termination of employment, or other adverse actions by the Requesting Party.

6. USE, RETENTION, AND CONFIDENTIALITY

Information disclosed in this Declaration may be retained in the Requesting Party's records for a period consistent with legitimate business or regulatory needs and in accordance with applicable law. The Requesting Party shall treat the information with reasonable confidentiality and limit disclosure to personnel and contractors who have a need to know or as otherwise required by law.

7. REPRESENTATIONS, WARRANTIES AND ACKNOWLEDGMENTS

The Declarant represents and warrants that all information provided in this Declaration is complete and accurate. The Declarant acknowledges that failure to disclose material information or providing false information constitutes a material breach of this Declaration and may subject the Declarant to legal penalties and adverse administrative action.

8. NOTICES

All notices required or permitted under this Declaration shall be in writing and delivered to the addresses below by hand delivery, certified mail, or other delivery method providing confirmation of receipt.

9. AMENDMENT; WAIVER; COUNTERPARTS

This Declaration may be amended only by a written instrument signed by both parties. No waiver of any provision shall be effective unless in writing and signed by the party against whom enforcement is sought. This Declaration may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one instrument.

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Declaration shall be governed by and construed in accordance with the laws of the jurisdiction identified by the Requesting Party's principal place of business, without regard to conflict of law principles. This Declaration constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior agreements and understandings, whether written or oral. If any provision of this Declaration is held invalid or unenforceable, the remainder of the Declaration shall remain in full force and effect.

11. MISCELLANEOUS PROVISIONS

The parties agree to cooperate in providing reasonable documentation to verify the disclosures herein. The Requesting Party's reliance on this Declaration shall be in accordance with applicable procedural safeguards and nondiscrimination requirements.

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