Legal Financial Information Form

LEGAL FINANCIAL INFORMATION FORM

This Legal Financial Information Form is made and entered into as of Date: by and between Party A (Discloser): whose principal address is and Party B (Recipient): whose principal address is .

RECITALS

WHEREAS, Discloser has access to financial records, account statements and related information that are relevant to the evaluation, negotiation, litigation, settlement or enforcement of certain claims or obligations between the parties; and

WHEREAS, Recipient requires verified financial information from Discloser for the sole purpose of assessing financial condition, resolving claims, or effecting a settlement, and Discloser is willing to provide such information subject to the terms and conditions set forth herein; and

WHEREAS, the parties intend that the disclosures made pursuant to this Form be relied upon by the parties and, when applicable, by counsel, auditors, opposing counsel, mediators, arbitrators, courts, or other authorized third parties as expressly permitted by this Form.

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained in this Form, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Form, the following terms shall have the meanings set forth below: "Confidential Information" means all nonpublic financial records, statements, tax returns, bank account information, credit reports, investment account information, asset lists, liabilities, supporting documents and any reproductions thereof; "Permitted Recipients" means the parties, their counsel, accountants, auditors, mediators, arbitrators, and courts to the extent necessary to evaluate, prosecute, defend, or resolve claims.

2. FINANCIAL INFORMATION TO BE PROVIDED

Discloser shall provide complete and current financial information responsive to the categories below. For each category, check "Attached" where supporting documentation is attached and provide requested details. If not applicable, check "None".

3. AUTHORIZATION TO OBTAIN RECORDS

Discloser authorizes Recipient, and Recipient's agents, counsel and authorized representatives, to request and obtain financial records and information from financial institutions, employers, tax authorities and other custodians of records to verify the statements made in this Form. This authorization covers records and information for the period from through unless a narrower period is specified in writing by the parties.

4. REPRESENTATIONS AND WARRANTIES; CERTIFICATION

Discloser represents and warrants that the financial information provided herein is true, complete and accurate to the best of Discloser's knowledge, and that no material fact or account has been omitted. Discloser understands that intentional misrepresentation or omission of material financial information may constitute fraud and may subject Discloser to civil and criminal penalties under applicable law.

Discloser certifies under penalty of perjury under the laws of the governing jurisdiction that the information provided in this Form is true and correct.

5. CONFIDENTIALITY AND USE

All Confidential Information produced pursuant to this Form shall be used solely for the purpose identified in the Recitals and shall not be disclosed except to Permitted Recipients or as required by law or court order. Recipient shall maintain reasonable safeguards to protect Confidential Information from unauthorized disclosure.

If disclosure is compelled by law, Recipient shall, to the extent legally permissible, provide prompt written notice to Discloser and cooperate in any effort to obtain protective relief or a qualified order.

6. NOTICES

All notices required or permitted under this Form shall be in writing and delivered to the addresses set forth below. Notice shall be deemed given when delivered in person, by a nationally recognized overnight courier, or three business days after deposit in the United States mail, postage prepaid.

7. AMENDMENTS; WAIVER; REMEDIES

This Form may be amended or modified only by a writing signed by both parties. No waiver of any provision of this Form shall be effective unless in writing and signed by the party against whom the waiver is asserted. Remedies provided in this Form are cumulative and in addition to any other remedies available at law or in equity.

8. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY; COUNTERPARTS

This Form shall be governed by and construed in accordance with the substantive laws of the state specified by the parties for governing law: , without regard to its conflict of laws principles.

This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether oral or written. If any provision of this Form is determined to be invalid, illegal or unenforceable, the remaining provisions shall remain in full force and effect.

This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Signatures transmitted by electronic means shall be binding.

9. MISCELLANEOUS PROVISIONS

Each party acknowledges that it has had the opportunity to seek independent legal counsel prior to executing this Form and that it fully understands the terms and legal effect of this Form.

The obligations and rights of the parties under this Form shall inure to their respective successors and permitted assigns. Neither party may assign its obligations hereunder without the prior written consent of the other party.

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