Legal Penalties of Perjury Form

LEGAL PENALTIES OF PERJURY FORM

This Legal Penalties of Perjury Form is entered into by and between Declarant Name: (Declarant) and Recipient Name: effective as of:

Recitals

WHEREAS, Declarant possesses certain factual information and written statements relating to the matters described in Section 2 below and wishes to certify the truthfulness of those statements; and

WHEREAS, Recipient requires a formal written certification and acknowledgment that the statements provided by Declarant are made under penalty of perjury and may be relied upon for administrative, contractual, or legal purposes; and

WHEREAS, the parties intend by this Form to set forth the certification, the consequences for false statements, and the parties' respective rights and remedies in connection therewith.

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, the following terms have the following meanings: "Certification" means the written statements and factual assertions made by Declarant in Section 2 below; "Declared Facts" means the facts described by Declarant and submitted to Recipient; "Applicable Law" means all federal, state, and local statutes, regulations, and common law governing civil and criminal penalties for false statements.

2. Certification and Representations

Declarant hereby certifies, under penalty of perjury, that the Declared Facts set forth below are true, complete, and correct to the best of Declarant's knowledge and belief as of the date of this Form. Declarant acknowledges that Recipient will rely upon the Certification in exercising rights, obligations, or making determinations.

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3. Penalty of Perjury Acknowledgment

Declarant affirms that the statements contained in the Certification are made under penalty of perjury. Declarant understands and agrees that knowingly making a false statement in the Certification may subject Declarant to civil and criminal penalties under Applicable Law, including monetary fines, forfeiture, and imprisonment, and may expose Declarant to civil liability for damages and attorneys' fees incurred by Recipient as a result of such falsehood.

4. Reliance; Use of Certification

Recipient may rely upon the Certification in good faith for administrative, contractual, regulatory, and litigation purposes. Recipient's reliance is a material inducement for Declarant to execute this Form. Recipient shall have no duty to independently verify the Declared Facts prior to taking action consistent with the Certification.

5. Remedies and Indemnification

In the event any part of the Certification is false, materially incomplete, or misleading, Recipient shall be entitled to pursue all remedies available at law or in equity, including rescission, damages, and injunctive relief. Declarant agrees to indemnify, defend, and hold harmless Recipient from and against any and all claims, losses, liabilities, costs, and expenses (including reasonable attorneys' fees) arising from or relating to any inaccurate or untrue statement contained in the Certification.

6. Notices

All notices, demands, or communications required or permitted under this Form must be in writing and delivered to the addresses provided below, or to any other address a party designates in writing pursuant to this Section.

7. Governing Law; Venue

This Form shall be governed by and construed in accordance with the laws of the State of without regard to conflict of laws principles. Any action arising out of or related to this Form shall be brought exclusively in the state or federal courts located in the chosen jurisdiction.

8. Entire Agreement; Severability

This Form constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written agreements and understandings relating thereto. If any provision of this Form is held to be invalid, illegal, or unenforceable, the remaining provisions shall remain in full force and effect and shall be interpreted so as to effectuate the parties' intent to the greatest extent permitted by law.

9. Amendments; Waiver; Counterparts

No amendment or modification of this Form shall be effective unless in writing and signed by both parties. No waiver of any breach shall be deemed waived unless in writing. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

10. Execution

Each party represents and warrants that the person signing on its behalf is authorized to do so and that the signature binds the respective party to the terms of this Form. This Form may be executed electronically or by ink signature.

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