Legal Name Correction Form

LEGAL NAME CORRECTION FORM

This Legal Name Correction Form is made and entered into on this date: by and between Requester Name: and Recipient Name: .

RECITALS

WHEREAS, Requester is currently recorded under the legal name ;

WHEREAS, Requester has requested that Recipient correct its records to reflect the correct legal name ; and

WHEREAS, Requester has submitted or will submit supporting documentation to substantiate the requested correction and Recipient is willing to update its records in accordance with the terms of this Form.

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. CORRECTION REQUEST

Requester hereby requests that Recipient correct all references in Recipient's records, files, certificates, registries, account listings and any other related records from the Current Legal Name to the Corrected Legal Name set forth above and take all administrative steps reasonably necessary to effectuate such correction.

2. SUPPORTING DOCUMENTATION

Requester represents that the following supporting documentation is submitted with this Form (check all that apply):

Birth certificate    Court order    Marriage certificate    Deed poll/Name change record

Government-issued identification    Other (describe below)

3. REPRESENTATIONS AND WARRANTIES

Requester represents and warrants to Recipient that: (a) Requester is the lawful owner of the Corrected Legal Name and has the full right and authority to request the correction; (b) the information and documentation provided to Recipient are true, complete and accurate in all material respects; and (c) the correction requested is not for the purpose of evading obligations, committing fraud, or otherwise avoiding legal process.

4. ENTITY AND PERSONAL IDENTIFIERS

Entity Type: Individual    Corporation    LLC    Trust    Other

Date of birth (if individual):    Former identifiers or account numbers, if any:

5. RECIPIENT OBLIGATIONS

Upon receipt of this Form and satisfactory supporting documentation, Recipient shall: (a) update its internal records to reflect the Corrected Legal Name; (b) where applicable, issue or reissue any certificates, statements or account records to reflect the Corrected Legal Name; and (c) provide written confirmation of the correction to Requester within days of receipt of complete documentation.

6. EFFECTIVE DATE

The correction described herein shall be effective as of: or, if no date is provided, upon Recipient's completion of internal processing related to the correction.

7. INDEMNIFICATION; LIMITATION OF LIABILITY

Requester shall indemnify, defend and hold harmless Recipient and its officers, directors, employees and agents from and against any and all claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees) arising out of or resulting from Requester's inaccuracy or misrepresentation in this Form or the supporting documents, or from any claim by a third party relating to the requested correction. Recipient's liability for any act or omission in connection with this Form shall be limited to direct damages and shall not include consequential, punitive or incidental damages.

8. FEES AND COSTS

Any fees or administrative costs incurred by Recipient in connection with performing the correction shall be borne by: Requester    Recipient    As otherwise agreed in writing

9. NOTICES

Notices under this Form shall be in writing and delivered to the addresses set forth below. Notices are effective upon personal delivery, one business day after deposit with a nationally recognized overnight courier, or three business days after mailing by first-class certified mail.

10. GOVERNING LAW; VENUE

This Form shall be governed by and construed in accordance with the laws of the state or jurisdiction identified below. The parties consent to the exclusive jurisdiction and venue of the state and federal courts located in that jurisdiction for any dispute arising under this Form.

Governing law jurisdiction:

11. ENTIRE AGREEMENT; SEVERABILITY; AMENDMENT

This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings and representations. If any provision of this Form is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Form may be amended or modified only by a writing signed by both parties.

12. COUNTERPARTS; EXECUTION

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. Electronic or facsimile signatures shall be valid and binding for all purposes.

CERTIFICATION

Requester certifies under penalty of perjury that the information provided in this Form and any accompanying documents is true and correct to the best of Requester's knowledge, and that Requester is authorized to request the correction set forth herein.

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