Legal Domiciliary Statement

LEGAL DOMICILIARY STATEMENT

This Legal Domiciliary Statement (the "Statement") is made as of by Declarant: whose mailing address is , and is delivered to Recipient: with address .

RECITALS

WHEREAS, Declarant is a natural person or legal entity whose principal place of habitation or business is located at ; and

WHEREAS, Declarant declares that the location specified above is the Declarant's true, fixed, and permanent domicile and that Declarant intends to remain at that domicile for the foreseeable future; and

WHEREAS, Recipient requires a formal written statement of domicile for purposes of establishing legal venue, tax residence, benefits eligibility, or other lawful purposes set forth herein.

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

1. DEFINITIONS

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

"Domicile" means the place where Declarant has a true, fixed, and permanent home and to which Declarant intends to return whenever absent.

"Effective Date" means the date inserted in the opening paragraph identified by the field labeled effective_date.

2. STATEMENT OF DOMICILE

Declarant hereby affirms and certifies that, as of the Effective Date, Declarant's domicile is: .

Declarant further states that Declarant has continuously resided at the foregoing address since and intends for such location to be Declarant's permanent home and principal place of abode.

3. ENTITY STATUS

Declarant represents that Declarant's organizational or personal status is indicated below (check one and complete additional fields as applicable):

Individual Corporation Trust Partnership Other:

4. REPRESENTATIONS AND WARRANTIES

Declarant represents and warrants to Recipient that: (a) Declarant is the person or legal entity named as Declarant in this Statement and has full authority to make the declarations herein; (b) the information set forth in this Statement is true, correct, and complete to the best of Declarant's knowledge and belief; and (c) there are no facts or circumstances known to Declarant that would materially alter the truth of the domiciliary information provided.

Declarant understands that Recipient may rely on this Statement for purposes of establishing legal venue, jurisdiction, tax residence, or eligibility for benefits, and Declarant agrees to notify Recipient in writing within thirty (30) days of any change in domiciliary status that would render this Statement inaccurate.

5. USE, RELIANCE, AND LIMITATION

Recipient may rely upon the representations and statements contained herein for the specific legal, administrative, or transactional purposes for which this Statement is provided. Recipient's reliance shall be limited to the facts expressly set forth in this Statement and any attachments expressly incorporated by reference.

6. INDEMNIFICATION

Declarant shall indemnify, defend, and hold harmless Recipient and its affiliates, officers, directors, agents and employees from and against any and all claims, losses, liabilities, damages, costs and expenses (including reasonable attorneys' fees) arising out of or resulting from any breach of the representations and warranties contained in this Statement or from any material misstatement or omission of fact by Declarant in this Statement.

7. NOTICES

Notices to Declarant:

Notices to Recipient:

8. GOVERNING LAW

This Statement shall be governed by and construed in accordance with the laws of the State of without regard to principles of conflicts of law. The parties submit to the exclusive jurisdiction of the state and federal courts located within that State for any action arising out of this Statement.

9. ENTIRE AGREEMENT

This Statement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings and statements, whether written or oral.

10. SEVERABILITY

If any provision of this Statement is held to be invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired.

11. AMENDMENT; WAIVER; COUNTERPARTS

This Statement may not be amended except by a written instrument signed by both parties. No waiver of any provision of this Statement shall be effective unless in writing and signed by the party against whom the waiver is asserted. This Statement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

12. ADDITIONAL STATEMENTS

CERTIFICATION

Declarant certifies under penalty of perjury that the information contained in this Statement is true and correct to the best of Declarant's knowledge and belief. Declarant acknowledges that false statements may subject Declarant to civil or criminal liability under applicable law.

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