Legal Opt In Declaration

LEGAL OPT IN DECLARATION

This Legal Opt In Declaration (the "Declaration") is made on this day of , by and between Declarant: , Address: ; and Recipient: , Address: .

Recitals

WHEREAS, Declarant has been provided with the materials, disclosures, and terms necessary to make an informed election regarding participation in the program, settlement, or service described in this Declaration; and

WHEREAS, Declarant desires to execute an affirmative election to opt in and to grant Recipient limited authority to process that election in accordance with the terms set forth below; and

WHEREAS, Recipient is authorized to accept and record opt-in elections on behalf of the program or proceeding identified herein and to take such actions as are reasonably necessary to effectuate Declarant's election.

NOW, THEREFORE, in consideration of the mutual covenants 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 shall have the meanings set forth below:

"Opt-In Election" means the affirmative, written declaration by Declarant contained in Section 2 by which Declarant elects to be included in the program, proceeding, or settlement identified in this Declaration.

"Program" means the specific program, settlement, or service described as: located at/with:

2. Declaration of Opt-In

Declarant hereby declares and affirms the following election (select one or more as applicable and initial where indicated):

Opt in to participation in the identified class action settlement or similar proceeding.

Opt in to participate in the Program or Service described above.

Consent to the processing and transfer of personal data as necessary to effectuate the Opt-In Election.

Declarant confirms the scope of the election as follows (describe any limitations or specific elections):

3. Representations and Warranties

Declarant represents and warrants that: (a) Declarant is at least eighteen (18) years of age and has the full legal capacity to execute this Declaration; (b) all information provided to Recipient in connection with this Declaration is true, correct and complete to the best of Declarant's knowledge; and (c) Declarant's execution of this Declaration does not violate any court order, agreement, or law to which Declarant is subject.

Declarant further represents that they have read, understand, and accept any terms, releases, limitations, or deadlines associated with the Program as disclosed to Declarant prior to signing.

4. Authorization and Consent

Declarant authorizes Recipient to take such actions as are reasonably necessary to record, memorialize, and process Declarant's Opt-In Election, including but not limited to submitting necessary paperwork to third parties, providing identifying information, and communicating with entities administering the Program. Declarant's authorization includes the limited disclosure of personal information to the extent required to effectuate the election.

Declarant acknowledges that Recipient's acceptance of the Opt-In Election is conditioned upon compliance with the Program's applicable rules and deadlines and that Recipient has no obligation to alter the Program's substantive terms.

5. Consideration

The parties agree that execution of this Declaration and the actions taken by Recipient in reliance hereon constitute sufficient consideration for Declarant's Opt-In Election. Declarant acknowledges that no further consideration beyond that provided by the Program is due from Recipient unless otherwise expressly stated in writing.

6. Confidentiality

Unless otherwise required by law or the Program, Recipient will treat information provided by Declarant in connection with this Declaration as confidential and will use such information only to process the Opt-In Election. Nothing in this Section limits Recipient's right to disclose information to third parties as reasonably necessary to effectuate the Opt-In Election or as required by applicable law.

7. Notices

All notices required or permitted under this Declaration shall be in writing and delivered to the addresses set forth in the opening paragraph or to such other address as a party may designate in writing. Notices shall be deemed given when received.

8. Amendments; Waiver; Counterparts

This Declaration may be amended only by a writing signed by both parties. No waiver of any provision of this Declaration shall be effective unless in writing and signed by the party against whom enforcement is sought. This Declaration may be executed in counterparts, each of which shall be an original and all of which together shall constitute one instrument.

9. Governing Law; Entire Agreement; Severability

This Declaration shall be governed by and construed in accordance with the laws of the State specified by the parties: , without regard to conflicts of law principles.

This Declaration constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings related to the Opt-In Election. If any provision of this Declaration is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

10. Miscellaneous Provisions

Each party represents that it has had the opportunity to seek independent legal counsel. The parties agree that any dispute arising out of or relating to this Declaration, after attempting good faith negotiation, may be resolved in accordance with any dispute resolution provisions of the Program or, if none, through competent courts of the governing state.

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