Legal Offense Declaration

LEGAL OFFENSE DECLARATION

This Legal Offense Declaration ("Declaration") is made as of Date: between Declarant Name: ("Declarant") and Recipient Name: ("Recipient").

RECITALS

WHEREAS, Recipient requires accurate disclosure of certain criminal, administrative, or disciplinary offenses and related factual information from individuals who seek employment, licensure, volunteer placement, contract engagement, or other affiliation with Recipient; and

WHEREAS, Declarant possesses personal knowledge of the facts and circumstances related to any offenses or potential offenses and is willing to provide a sworn declaration to facilitate Recipient's assessment; and

WHEREAS, the parties desire to memorialize the scope of disclosure, the duties of Declarant, and the legal effect of the representations and certifications contained herein.

NOW, THEREFORE, in consideration of the mutual promises set forth 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 Declaration, the following terms shall have the meanings set forth below:

"Offense" means any arrest, charge, indictment, complaint, conviction, plea, diversion, nolo contendere, administrative finding, professional discipline, or similar formal allegation or determination by any law enforcement, prosecutorial, regulatory, or licensing authority.

"Disposition" means the final outcome of an Offense, including but not limited to dismissal, acquittal, conviction, plea agreement, expungement, deferred adjudication, or sentencing.

2. REPRESENTATIONS AND DECLARATIONS OF THE DECLARANT

Declarant represents and warrants to Recipient that Declarant has made full and complete inquiry into Declarant's history and now provides the disclosures below under penalty of perjury and subject to the certifications in Section 7.

Have you ever been subject to any Offense as defined above?   Yes No

3. DETAILED OFFENSE DISCLOSURES

Declarant shall list each Offense known to Declarant. If no Offenses, enter "None" in the first Offense Description. Attach additional pages if necessary and indicate the number of additional pages below.

Offense 1

Offense 2

4. SUPPORTING DOCUMENTATION

Declarant must attach certified copies of all court dispositions, orders, plea agreements, certificates of completion, or official documents that relate to any disclosed Offense. Indicate attachments below and attach originals or certified copies to this Declaration.

5. CONSENT TO INQUIRIES

Declarant consents to reasonable inquiries, verification, or background checks by Recipient or its authorized agents relating to any disclosed Offense. Consent is limited to records necessary to confirm the accuracy of the Declarant's statements and to confirm disposition documentation.

6. NOTICES

All notices, requests, demands and other communications required or permitted hereunder shall be in writing and delivered to the parties at the addresses provided below.

7. ACKNOWLEDGMENT, CERTIFICATION AND CONSEQUENCES

Declarant certifies under penalty of perjury under applicable law that the information contained in this Declaration is true, complete and correct to the best of Declarant's knowledge as of the date signed. Declarant acknowledges that a material misstatement, omission, or failure to disclose relevant facts may constitute grounds for denial of an application, termination of a relationship, revocation of licensure, civil liability, criminal exposure, or other corrective measures permitted by law.

Declarant further agrees to promptly supplement or amend this Declaration if new information relevant to any Offense arises subsequent to the date of this Declaration and prior to the termination of any relationship with Recipient that is conditioned on this disclosure.

8. MISCELLANEOUS

Governing Law: This Declaration shall be governed by and construed in accordance with the substantive laws of the jurisdiction specified by the Recipient's notice address without regard to conflict of laws principles.

Entire Agreement: This Declaration constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior or contemporaneous written or oral agreements, representations, and understandings.

Severability: If any provision of this Declaration is held to be invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall continue in full force and effect.

Amendments and Waiver: No amendment or waiver of any provision of this Declaration shall be effective unless in writing and signed by both parties. No failure or delay by either party in exercising any right shall constitute a waiver of that right.

Counterparts: 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.

9. SIGNATURES

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