Legal Name Certificate

LEGAL NAME CERTIFICATE

This Legal Name Certificate (the Certificate) is executed on this day of , by and between Certifying Authority: with mailing address and Applicant / Subject: whose address is .

RECITALS

WHEREAS, Applicant seeks formal certification of Applicant's legal name for use in contracts, government filings, banking, and other official records;

WHEREAS, Certifying Authority is authorized under its organizational instruments and applicable law to issue certificates attesting to the legal name of an individual or entity within the scope described herein;

WHEREAS, Applicant has provided documentation and declarations to Certifying Authority, and Certifying Authority has reviewed such documentation and is satisfied that certification is appropriate under the representations set forth below;

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

1. DEFINITIONS

1.1 "Certified Name" means the legal name of Applicant as set forth in Section 2 of this Certificate. "Documentation" means the identity, court, or administrative records provided by Applicant to support the requested certification.

2. CERTIFICATION

2.1 Certifying Authority hereby certifies that, based upon the Documentation presented and subject to the representations of Applicant, the legal name of Applicant is:

2.2 Effective Date of Certification:

3. REPRESENTATIONS AND WARRANTIES

3.1 Applicant represents and warrants that all information and Documentation provided to Certifying Authority are true, complete and accurate in all material respects, and that Applicant has the right to request and receive the certification sought.

3.2 Certifying Authority represents and warrants that this Certificate is issued only after review of the Documentation and in accordance with its standard procedures. Certifying Authority makes no warranty beyond the scope of the documentation reviewed and expressly disclaims liability for misrepresentation by third parties.

4. LIMITATIONS ON USE AND RELIANCE

4.1 This Certificate may be relied upon by third parties only to the extent expressly set forth herein. Reliance by any third party other than those identified in this Certificate is at such third party's sole risk.

4.2 This Certificate does not constitute a determination of legal status beyond the Certified Name, nor does it substitute for court or governmental orders when such orders are required to effect a legal name change for statutory purposes.

5. RECORDS AND NOTICE

5.1 Certifying Authority will retain records regarding this Certification for a period consistent with its record retention policy and applicable law. Applicant consents to such retention and to reasonable disclosure to governmental authorities upon lawful request.

6. FEES AND COSTS

6.1 Applicant shall be responsible for any fees charged by Certifying Authority in connection with the issuance of this Certificate. Payment of such fees does not alter the limitations of liability set forth herein.

7. GOVERNING LAW

This Certificate shall be governed by and construed in accordance with the laws of the jurisdiction stated below, without regard to conflict of law principles.

8. ENTIRE AGREEMENT

This Certificate constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, and communications, whether written or oral, relating thereto.

9. SEVERABILITY

If any provision of this Certificate is held to be invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not be affected or impaired thereby.

10. AMENDMENTS; WAIVER; COUNTERPARTS

10.1 No amendment to this Certificate shall be effective unless in writing and signed by both parties. No waiver of any provision shall be effective unless in writing and signed by the waiving party. This Certificate 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. CERTIFICATION AND PENALTIES

The undersigned Certifying Authority certifies under penalty of perjury that the facts stated in this Certificate are true and correct to the best of such party's knowledge and belief. Applicant acknowledges that false statements or fraudulent use of this Certificate may result in civil and criminal penalties under applicable law.

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