Legal Identification Declaration

LEGAL IDENTIFICATION DECLARATION

This Legal Identification Declaration (the Declaration) is made and entered into on Effective Date: by and between Declarant Name: whose residential address is and Recipient Name: whose address for service is .

RECITALS

WHEREAS, Declarant seeks to certify and present accurate legal identification information to Recipient for purposes of verifying identity, completing transactions, maintaining regulatory records and other lawful purposes as set forth herein; and

WHEREAS, Recipient requires a formal, sworn declaration of identity and supporting documentation from Declarant in order to rely upon Declarant's representations in connection with administrative, contractual, or legal matters; and

WHEREAS, Declarant will provide copies of government-issued identification and other supporting records and will certify the accuracy of such copies under penalty of law.

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

1. DEFINITIONS

For purposes of this Declaration: (a) "Declarant" means the individual identified above who attests to the accuracy of the Identification Information; (b) "Recipient" means the entity or person identified above receiving and relying upon such Identification Information; and (c) "Identification Documents" means government-issued identification and official records provided by Declarant and described in Section 3.

2. DECLARATION OF IDENTITY

Declarant affirms, represents and warrants that the following Identification Information is true, correct and complete as of the Effective Date:

Legal Name:

Date of Birth:   Place of Birth:

Current Residence:

Primary Government-Issued Identification: Type:  Number:  Issuing Authority:

Issue Date:   Expiration Date:

3. SUPPORTING DOCUMENTATION

Declarant certifies that true, legible copies of the following Identification Documents are provided to Recipient (check all that apply):

Driver's License / State ID

Passport

Birth Certificate

Other (describe below)

Declarant further affirms that the copies delivered to Recipient are true and complete copies of the original Identification Documents and that the originals are available for inspection upon reasonable request.

4. REPRESENTATIONS AND WARRANTIES

Declarant represents and warrants that: (a) Declarant is the person named in the Identification Information and has the legal capacity to make this Declaration; (b) all information provided is true, complete, and not misleading; (c) there are no pending legal proceedings that would affect the truth of the facts stated herein; and (d) any change in the Identification Information that materially affects Recipient's reliance will be promptly disclosed in writing.

5. USE, RETENTION AND DISCLOSURE

Recipient may use and retain the Identification Information and supporting copies for legitimate business, regulatory, contractual and legal purposes. Recipient shall treat such information consistent with applicable privacy and data protection obligations and shall not disclose this Declaration or supporting documents to third parties except as required by law, regulation, or valid legal process, or to those agents, advisors or contractors on a need-to-know basis subject to confidentiality obligations.

6. CERTIFICATION AND PENALTIES

Declarant certifies under penalty of perjury that the information contained in this Declaration and the attached Identification Documents is true, correct and complete to the best of Declarant's knowledge. Declarant understands that making a material false statement in a sworn declaration may expose Declarant to civil and criminal penalties under applicable law.

State of Jurisdiction for Purposes of Penalty of Perjury:

7. INDEMNITY

Declarant agrees to indemnify, defend and hold harmless Recipient and its officers, directors, employees and agents from and against any and all claims, losses, liabilities, damages, costs and expenses (including reasonable attorneys' fees) arising out of or resulting from a material breach of the representations or warranties in this Declaration or from any intentional misstatement or omission made by Declarant in connection with this Declaration.

8. NOTICES

All notices or communications required or permitted under this Declaration shall be in writing and delivered to the addresses set forth below.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Declaration shall be governed by and construed in accordance with the laws of the State of without regard to its conflicts of law principles. This Declaration constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior oral or written understandings. If any provision of this Declaration is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

10. AMENDMENT; WAIVER; COUNTERPARTS

No amendment or waiver of any provision of this Declaration shall be effective unless in writing and signed by both parties. Failure to enforce any right shall not constitute a waiver of that right. This Declaration 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.

11. MISCELLANEOUS

The headings in this Declaration are for convenience only and shall not affect the interpretation of any provision. Any reference to a party includes that party's successors and permitted assigns. If the Declarant is executing this Declaration on behalf of another person or entity, Declarant must identify capacity and authority below.

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