Legal Exemption Application

LEGAL EXEMPTION APPLICATION

This Legal Exemption Application is submitted by Applicant Name: (Applicant), an entity of type Individual Corporation Nonprofit Government Agency, with principal address: , submitted to Authority Name: (Authority) on Date Submitted: .

RECITALS

WHEREAS, Applicant seeks a formal exemption from the obligations described in Statute/Regulation Citation: on the grounds described in this Application; and

WHEREAS, Authority has authority under applicable law to consider and grant exemptions in specific circumstances and to impose terms and conditions as necessary to protect public interest; and

WHEREAS, Applicant represents that the facts and documentation submitted with this Application are true, complete, and accurate to the best of Applicant’s knowledge and belief.

NOW, THEREFORE, in consideration of the submission and review of this Application, Applicant and Authority agree as follows:

1. APPLICATION AND REQUEST

1.1 Applicant hereby requests an exemption described as: . The requested effective period is from to .

2. GROUNDS FOR EXEMPTION; SUPPORTING FACTS

2.1 Applicant certifies that the exemption is sought on one or more of the following grounds (check all that apply) and provides supporting factual statements and documentation below:

Substantial economic hardship; Redundant or duplicative regulation as applied to Applicant; Confidential proprietary information requiring special handling; Other (describe below).

3. ELIGIBILITY ATTESTATIONS

Applicant attests under penalty of perjury that all of the following are true and correct (initial each applicable statement):

Applicant is in substantial compliance with material requirements other than the clauses from which exemption is sought.
Applicant has no unresolved administrative orders or final judgments relating to the same subject matter.
Applicant will comply with any conditions imposed by Authority as a condition of exemption.

4. SUPPORTING DOCUMENTATION

4.1 Applicant shall attach and describe all documents provided to support this Application. List of attachments:

5. REVIEW PROCESS; CONDITIONS

5.1 Authority will review the Application for completeness and may request additional information. Authority may grant the requested exemption in whole or in part, deny the Application, or grant the exemption subject to conditions reasonably calculated to further the public interest. The decision will be issued within the Authority’s applicable review period of calendar days after receipt of a complete Application.

6. FEES; FEE WAIVER

6.1 Application Fee: Applicant acknowledges payment of the required fee in the amount of $ or seeks a fee waiver.

Fee waiver requested. If fee waiver is requested, Applicant must set forth the basis for waiver in the Statement of Facts above.

7. REPRESENTATIONS; CERTIFICATIONS; AUTHORIZATION

7.1 Applicant represents and certifies that all information and documentation provided with this Application are true, complete and correct. Applicant understands that a material misstatement or omission may constitute grounds for denial or revocation of any exemption granted and may subject Applicant to civil or criminal penalties under applicable law.

7.2 Applicant authorizes Authority to verify any information provided, to obtain additional information from third parties, and to share information with other governmental entities as required by law or regulation.

8. NOTICES

9. MISCELLANEOUS

Governing Law: This Application and any exemption granted pursuant to it shall be governed by and construed in accordance with the laws of the applicable jurisdiction where Authority has jurisdiction.

Entire Agreement: Any exemption granted pursuant to this Application, together with any conditions expressly stated by Authority in a written grant, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior agreements and understandings, whether written or oral.

Severability: If any provision of this Application is held invalid or unenforceable, the remainder of the Application will remain in full force and effect and will be construed so as to effectuate the original intent of the parties to the maximum extent permitted by law.

Amendments; Waiver: No amendment to this Application is effective unless in writing and signed by both Applicant and Authority. No waiver of any provision is effective unless in writing signed by the party waiving compliance.

Counterparts: This Application may be executed in counterparts, each of which is an original and all of which together constitute one instrument.

ACKNOWLEDGMENT

By signing below, the undersigned each certify under penalty of perjury that they are authorized to submit this Application and to bind the party on whose behalf they sign; that the information provided is true and correct; and that they understand the conditions and consequences of making false statements.

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