Legal Identification Document

LEGAL IDENTIFICATION DOCUMENT

This Legal Identification Document is made and entered into by and between Identified Person: and Certifying Party: . Effective Date:

RECITALS

WHEREAS, Identified Person seeks to establish their legal identity and to authorize the Certifying Party to examine, record, and certify certain identification documents for purposes of verification, record retention and permitted legal uses; and

WHEREAS, Certifying Party is an authorized representative, agent or official with authority to examine identity documentation and to certify that copies of such documentation are true, complete and accurate to the best of its knowledge; and

WHEREAS, the parties desire to set forth in writing the specific identification presented, the representations made by the Identified Person, and the certification and reliance provisions applicable to copies and records retained by the Certifying Party.

NOW THEREFORE

In consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Document, "Identification Documents" means those government-issued documents listed in Section 2 and any additional document reasonably requested and accepted by Certifying Party. "Certify" and "Certification" mean a written attestation by the Certifying Party that a copy of an Identification Document is a true and correct copy of the original examined.

2. IDENTIFICATION DETAILS

The Identified Person presented the following Identification Documents to the Certifying Party on the Effective Date (check all that apply and supply required details).

Issuing Authority: Number: Issue Date: Expiration Date:

Issuing Authority: Number: Issue Date: Expiration Date:

Issuing Authority: Number: Issue Date: Expiration Date:

Describe: Number:

3. ATTESTATION BY IDENTIFIED PERSON

The Identified Person hereby represents and warrants under penalty of perjury that all information provided in this Document, and any identification presented to the Certifying Party, is true, complete and correct. The Identified Person acknowledges that knowingly making a false statement or providing false identification may subject the Identified Person to civil or criminal penalties under applicable law.

The Identified Person consents to the Certifying Party retaining copies or electronic images of presented Identification Documents for the purposes of verification, recordkeeping, and compliance with legal obligations. The Identified Person authorizes the Certifying Party to contact issuing authorities to confirm the authenticity of presented documents where reasonably necessary.

4. CERTIFICATION BY CERTIFYING PARTY

Upon examination of the original Identification Documents referenced in Section 2, the Certifying Party certifies that the attached copies or records are, to the Certifying Party's knowledge after reasonable review, true and correct reproductions of the originals. The Certifying Party's Certification is limited to comparison of the copy with the original documents physically exhibited to the Certifying Party on the Effective Date and does not extend to any subsequent changes in identity or status.

The Certifying Party shall exercise reasonable care and professional diligence in making such Certification but does not assume liability for inaccuracies in original documents created by third parties. The Certifying Party's Certification is provided solely for the benefit of the parties and entitled third parties who reasonably rely on this Document.

5. RELIANCE, INDEMNITY AND LIMITATION OF LIABILITY

Any person or entity that relies on the Certification herein does so at its own risk. The Identified Person agrees to indemnify, defend and hold harmless the Certifying Party from and against any losses, liabilities, damages, costs and expenses (including reasonable attorneys' fees) arising from any inaccuracy or misstatement made by the Identified Person in connection with this Document.

Except for willful misconduct or gross negligence, the Certifying Party's liability for any claim arising out of or related to this Document shall be limited to direct damages and in no event shall the Certifying Party be liable for incidental, consequential or punitive damages.

6. PRIVACY, RECORDS RETENTION AND DESTRUCTION

The Certifying Party will maintain copies of Identification Documents in physical or electronic form in a secure manner for a retention period consistent with its legal obligations and internal policy. Upon expiration of the retention period, the Certifying Party may destroy or anonymize records in a manner designed to protect Identified Person's personal data from unauthorized disclosure.

7. NOTICES

All notices required or permitted under this Document shall be in writing and delivered to the addresses set forth below (or to such other address as a party designates in writing). Delivery by hand, recognized overnight courier or by certified mail shall be deemed effective upon receipt.

8. AMENDMENTS, WAIVER AND COUNTERPARTS

No amendment to this Document shall be effective unless in writing and signed by both parties. No waiver of any provision shall be deemed a further or continuing waiver. This Document may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Document shall be governed by and construed in accordance with the laws of the jurisdiction selected by the parties below. This Document constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior agreements and understandings. If any provision of this Document is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

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