Legal Ownership Report

LEGAL OWNERSHIP REPORT

This Legal Ownership Report is made as of by Reporting Party: with address , and submitted to Recipient: with address .

RECITALS

WHEREAS, the Reporting Party holds or controls certain ownership interests in the entity identified below and is required or elects to report the nature and extent of such ownership to the Recipient pursuant to applicable corporate governance, contractual or regulatory obligations;

WHEREAS, the entity to which this report pertains (the "Reported Entity") is identified as: Name: ; Jurisdiction of formation: ; Registration/ID number: .

WHEREAS, the Reporting Party makes the representations and disclosures contained in this report to enable the Recipient to maintain accurate ownership records, to satisfy due diligence obligations, and for other lawful corporate, regulatory or contractual purposes.

NOW THEREFORE

In consideration of the mutual covenants set forth herein, the Reporting Party and the Recipient agree as follows:

1. DEFINITIONS

For purposes of this Report, the following terms shall have the meanings set forth below:

"Beneficial Owner" means any natural person or legal entity that, directly or indirectly, exercises voting power, investment control, or receives economic benefits from an ownership interest in the Reported Entity, including through chains of ownership or agreements.

"Ownership Interest" means any equity, membership, partnership interest, convertible instrument or other contractual or legal right to acquire equity that conveys the right to economic benefits or governance influence.

2. OWNERSHIP INFORMATION

The Reporting Party discloses the following ownership details as of the Report Date.

3. BENEFICIAL OWNERS (PRIMARY)

Identify up to three primary beneficial owners. For each owner, provide the information requested. If additional owners exist, list them in Section 4.

4. ADDITIONAL OWNERS AND CHAINS OF OWNERSHIP

5. SUPPORTING DOCUMENTS

Attach or identify documentary evidence relied upon for the disclosures made herein. Check applicable document types and list file identifiers or reference numbers.

6. REPRESENTATIONS, WARRANTIES AND COVENANTS

The Reporting Party represents and warrants that: (a) the information provided in this Report and in any attachments is true, correct and complete to the best of its knowledge and belief; (b) no material fact has been omitted that would render the disclosures misleading; (c) it will promptly notify the Recipient in writing of any material change to the ownership information disclosed herein; and (d) it has authority to make the disclosures and certifications contained in this Report.

The Reporting Party acknowledges that the Recipient may rely on the information contained in this Report in the exercise of corporate or regulatory duties and that knowingly providing false information may give rise to contractual, administrative or civil remedies.

7. CONFIDENTIALITY AND USE

The Recipient shall handle the information in this Report in accordance with its confidentiality obligations and applicable law. The Recipient may disclose information to regulators, auditors, legal counsel or as required by law or court order. The Recipient's use of the information shall be limited to purposes of compliance, recordkeeping and risk management unless otherwise agreed in writing.

8. NOTICES

All notices and communications required or permitted under this Report shall be in writing and delivered to the addresses provided in the opening paragraph or as later updated in writing by either party. Notice is effective upon receipt.

9. AMENDMENTS; WAIVER; COUNTERPARTS

This Report may be amended only by a written instrument executed by both parties. No failure or delay in exercising any right shall operate as a waiver. This Report may be executed in counterparts and by electronic or facsimile signature, each of which shall constitute an original and all of which together shall constitute one instrument.

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Report shall be governed by and construed in accordance with the laws of , without regard to conflict of law principles. This Report constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior understandings. If any provision is found invalid or unenforceable, the remaining provisions shall remain in full force and effect.

11. CERTIFICATION

The undersigned, on behalf of the Reporting Party, certifies under penalty of perjury under the laws of the jurisdiction identified above that the information contained in this Legal Ownership Report and any attachments is true, correct and complete to the best of the signatory's knowledge after due inquiry.

Sign Now