Legal Not Dependent Form

LEGAL NOT DEPENDENT FORM

This Legal Not Dependent Form (this "Declaration") is made and entered into as of Effective Date: by and between Requesting Party: with address: and Declarant: with address: .

Recitals

WHEREAS, Requesting Party requires a formal written certification that Declarant is not and will not be claimed as a dependent of any other person or entity for specified tax period(s) or for purposes of benefit eligibility; and

WHEREAS, Declarant represents that Declarant is an independent individual and, as of the Effective Date, meets the criteria to assert non-dependent status under applicable federal and state law for the tax year(s): ; and

WHEREAS, the parties desire to set forth the certification, warranties, and remedies regarding Declarant's non-dependent status.

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein, 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 Declaration, the following terms have the meanings set forth below:

(a) "Dependent" means an individual who may be claimed as a dependent on another person's federal or state income tax return under applicable statutory and regulatory tests, including but not limited to tests of relationship, residency, support and gross income.

(b) "Tax Year(s)" means the tax year or years specified in the Tax Year(s) field above.

2. Declaration of Non-Dependent Status

Declarant hereby certifies, represents and warrants to Requesting Party that, as of the Effective Date and for the Tax Year(s) specified, Declarant is not a Dependent of any other person or entity and will not be claimed as a Dependent on any federal, state or local tax return filed by any person or entity for those Tax Year(s).

Declarant further represents that Declarant's facts and circumstances satisfy the applicable tests for independent status and that Declarant is solely responsible for Declarant's own support, residency and tax reporting for the Tax Year(s).

3. Supporting Documentation

Upon request by Requesting Party, Declarant shall provide copies of reasonable supporting documentation demonstrating non-dependent status, including but not limited to filed tax returns, affidavit(s) of third parties, rental or residency agreements, or payroll records. Failure to provide requested documentation within days constitutes a breach of this Declaration.

4. Change in Status; Notice

Declarant shall promptly notify Requesting Party in writing within days of any change that would cause Declarant to become a Dependent for any Tax Year, including where Declarant becomes eligible to be claimed as a Dependent by another person or entity.

5. Indemnification

Declarant shall indemnify, defend and hold harmless Requesting Party and its directors, officers, employees and agents from and against any and all claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees and costs of investigation) arising out of or resulting from (a) any breach of the representations and warranties made by Declarant in this Declaration; or (b) any claim by a tax authority or third party that Declarant was improperly represented or treated as not being a Dependent.

6. Remedies

In addition to any other remedies available at law or in equity, Requesting Party shall be entitled to injunctive relief to prevent any breach or threatened breach of this Declaration as well as recovery of all damages, costs and expenses (including attorneys' fees) incurred as a result of Declarant's breach.

7. Notices

Any notice required or permitted under this Declaration must be in writing and delivered to the addresses below (or such other address as a party may specify in writing). Notice is effective upon receipt.

8. Governing Law

This Declaration shall be governed by and construed in accordance with the laws of the state of , without giving effect to conflict of law principles that would result in the application of the law of another jurisdiction.

9. Entire Agreement

This Declaration contains the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written, of the parties.

10. Severability

If any provision of this Declaration is held to be invalid, illegal or unenforceable for any reason, the remaining provisions shall continue in full force and effect and the parties shall negotiate in good faith to replace the invalid, illegal or unenforceable provision with a valid provision that most closely approximates the original intent.

11. Amendments; Waiver; Counterparts

No amendment, modification or waiver of any provision of this Declaration shall be effective unless in writing and executed by both parties. Failure or delay by either party to exercise any right shall not operate as a waiver of that right. This Declaration may be executed in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument.

12. Certification

Declarant certifies, under penalty of perjury under the laws of the governing state specified above, that the foregoing statements are true, correct and complete to the best of Declarant's knowledge and belief. Declarant acknowledges that any willful misrepresentation may subject Declarant to civil and criminal penalties.

Declarant acknowledges and agrees that Requesting Party may rely on this Declaration in connection with eligibility determinations, benefit processing, or compliance obligations.

I certify under penalty of perjury that I am not and will not be claimed as a Dependent for the Tax Year(s) specified and that all information provided in this Declaration is true and complete.

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