Legal Patriot Act Form

LEGAL PATRIOT ACT FORM

This Legal Patriot Act Form is executed on this date: by and between Client Name: with principal address: ("Client") and Institution Name: with principal address: ("Institution").

RECITALS

WHEREAS, federal law requires financial institutions and certain covered persons to obtain, verify and record information that identifies each person who opens an account or establishes a relationship, to assist in the prevention of money laundering and terrorist financing (collectively, the "PATRIOT ACT obligations"); and

WHEREAS, the Institution requires the Client to provide identifying information, certifications, and acknowledgements necessary for the Institution to satisfy applicable PATRIOT ACT obligations and its internal anti-money laundering, sanctions screening and beneficial ownership policies; and

WHEREAS, the Client agrees to provide accurate information and authorizes reasonable verification procedures as set forth in 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. DEFINITIONS

For purposes of this Form, "Beneficial Owner" means any natural person who, directly or indirectly, (a) owns 25% or more of the equity interests of the Client entity, or (b) exercises significant control over the Client entity by means of senior management, senior officers, executive decision-making, or similar authority. "Identification Information" means documents or data sufficient to establish the identity of a natural person or legal entity under applicable law.

2. IDENTIFICATION AND CERTIFICATION

The Client certifies that the Identification Information supplied below is true, accurate and complete and authorizes the Institution to verify such information by any lawful means. The Client shall promptly provide additional documentation upon the Institution's request.

3. ENTITY TYPE

The Client represents and warrants its organization type by selecting the applicable box(es) below.

Individual    Corporation    Limited Liability Company    Partnership    Trust    Other:

4. BENEFICIAL OWNERSHIP

The Client shall disclose all Beneficial Owners as defined herein. If no Beneficial Owner meets the definition, the Client must check the box below and provide the controlling individual (control person) information.

Client declares no Beneficial Owner meeting the defined threshold; control person information provided below.

5. REPRESENTATIONS AND WARRANTIES

The Client represents and warrants that (a) all information and documentation provided to the Institution in connection with this Form are true, complete and correct; (b) the Client is not subject to sanctions, does not appear on any government-designated prohibited parties list, and is not otherwise disqualified from conducting business under applicable anti-money laundering, counter-terrorist financing, or sanctions laws; and (c) the Client will promptly notify the Institution in writing of any material change to such information.

6. COMPLIANCE, VERIFICATION AND RECORDS

The Client authorizes the Institution to take any actions reasonably necessary to verify the information supplied, including obtaining and retaining copies of identification documents, querying public and private databases, screening against restricted party lists, and disclosing information to auditors or governmental authorities where required by law. The Institution may retain records of such verification as required by law and policy.

7. CONFIDENTIALITY AND DATA USE

The Institution will treat non-public information provided by the Client as confidential, subject to disclosure as required by law or regulation. The Client consents to the use and disclosure of Identification Information and beneficial ownership data for compliance and reporting purposes and acknowledges that such disclosures may occur without additional consent where legally required.

8. INDEMNIFICATION

The Client shall indemnify, defend and hold harmless the Institution and its officers, directors, employees and agents from and against any and all claims, losses, liabilities, costs and expenses (including reasonable attorneys' fees) arising out of or in connection with any misrepresentation, breach of warranty, or failure to provide complete and accurate information under this Form.

9. NOTICES

All notices required or permitted under this Form shall be in writing and delivered to the addresses set forth below (or such other address as a party may designate by written notice).

10. AMENDMENTS; WAIVER

No amendment or waiver of any provision of this Form shall be effective unless in writing and signed by both parties. No failure or delay by either party in exercising any right shall operate as a waiver of such right.

11. GOVERNING LAW

This Form shall be governed by and construed in accordance with the laws of the jurisdiction where the Institution's primary office is located, without regard to conflict of law principles.

12. ENTIRE AGREEMENT; SEVERABILITY

This Form constitutes the entire agreement between the parties with respect to the subject matter hereof. If any provision of this Form is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

13. COUNTERPARTS

This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. Signatures delivered by electronic means shall have the same force and effect as original signatures.

14. CERTIFICATION

By signing below, the undersigned certifies, under penalty of law, that the information provided in this Form is true, correct and complete to the best of the undersigned's knowledge, and that the undersigned is authorized to provide such information on behalf of the Client.

Client certifies that the information provided is true, accurate, and complete.

Sign Now