Legal Exemption Affidavit

Legal Exemption Affidavit

This Legal Exemption Affidavit is executed on this by Affiant Name: , whose primary address is , and submitted to Requesting Party Name: , with business address .

RECITALS

WHEREAS, Affiant seeks a formal declaration that Affiant is exempt from the obligation described herein on the basis specified below; and

WHEREAS, Requesting Party requires a sworn statement that establishes the facts and legal basis supporting the claimed exemption and any conditions attached thereto; and

WHEREAS, Affiant declares under oath that the statements contained in this affidavit are true and accurate to the best of Affiant's knowledge, information and belief.

NOW, THEREFORE

NOW, THEREFORE, in consideration of the mutual covenants set forth herein and for other good and valuable consideration, the receipt and sufficiency of which are acknowledged, Affiant and Requesting Party agree as follows:

1. DEFINITIONS

For purposes of this Affidavit, the following terms have the meanings set forth below. "Exemption" means the relief, exclusion, or waiver claimed by Affiant from the obligation identified in Section 2. "Supporting Documentation" means the contemporaneous records, certifications, or other documentary evidence provided by Affiant in support of the Exemption claim.

2. STATEMENT OF EXEMPTION

Affiant hereby declares that Affiant claims an exemption from:

Tax withholding exemption
Licensing or registration exemption
Religious exemption
Medical exemption
Other:

Legal basis or statutory citation supporting the claimed exemption:

3. FACTUAL STATEMENT

Affiant affirms the following facts under penalty of perjury. Describe the material facts that give rise to the exemption claim, including dates, transactions, and parties involved:

4. SUPPORTING DOCUMENTATION

Affiant has attached or will furnish the following documents in support of this Affidavit (check applicable and describe if necessary):

Written statements or declarations
Certificates or official records
Medical records or provider certification
Other:

5. AFFIRMATION, OATH AND CERTIFICATION

Affiant affirms under oath that the statements made in this Affidavit are true, complete and correct to the best of Affiant's knowledge and belief. Affiant understands that any material misstatement, omission, or falsification of fact may constitute perjury and may subject Affiant to civil or criminal penalties under applicable law.

Affiant further certifies that Affiant will notify Requesting Party in writing within days of any change in circumstances that would affect the validity of the claimed exemption.

6. SCOPE AND DURATION

The exemption claimed is effective as of and will remain in effect until unless earlier terminated, revoked, or superseded by a final determination of competent authority.

7. REPRESENTATIONS AND WARRANTIES

Affiant represents and warrants that Affiant has full authority to execute this Affidavit and that no material facts have been omitted. Affiant further warrants that Affiant will supply additional information or documentation reasonably requested by Requesting Party in connection with verification of the claimed exemption.

8. INDEMNIFICATION

To the extent permitted by law, Affiant agrees to indemnify, defend and hold Requesting Party harmless from and against any and all claims, losses, liabilities, damages, costs and expenses (including reasonable attorneys' fees) resulting from any materially false statement, misrepresentation or omission contained in this Affidavit or in any supporting documentation.

9. NOTICES

Any notice required or permitted under this Affidavit shall be in writing and delivered to the addresses set forth below or to such other address as a party may designate in writing:

10. AMENDMENT; WAIVER; COUNTERPARTS

No amendment or waiver of any provision of this Affidavit shall be effective unless in writing and signed by both Affiant and Requesting Party. The failure of either party to enforce any provision of this Affidavit shall not constitute a waiver of future enforcement. This Affidavit may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Affidavit shall be governed by and construed in accordance with the laws of the state specified below without regard to conflict of laws principles. This Affidavit constitutes the entire agreement of the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written. If any provision of this Affidavit is held to be invalid or unenforceable, such provision shall be severed and the remaining provisions shall remain in full force and effect.

12. ADDITIONAL ACKNOWLEDGMENTS

Affiant acknowledges that Requesting Party may verify the accuracy of the statements and supporting documentation provided herein and authorizes the release of information necessary to confirm the asserted facts.

SWORN DECLARATION

I, the undersigned Affiant, declare under penalty of perjury under the laws of the governing jurisdiction that the foregoing statements are true and correct.

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