Legal Perjury Statement

LEGAL PERJURY STATEMENT

This Legal Perjury Statement is executed on this date by Declarant Name: whose residence or principal place of business is at Address: (the "Declarant"), and is provided to Recipient Name: with address Recipient Address: for the purposes set forth herein.

RECITALS

WHEREAS, Declarant has provided or will provide written statements, documents, and other information concerning Matter Description: to Recipient in connection with the above-referenced matter; and

WHEREAS, Recipient requires a sworn certification that the facts, statements, and documents provided by Declarant are true and correct under penalty of perjury; and

WHEREAS, Declarant desires to make such certification and to acknowledge the legal consequences for knowingly providing false statements.

NOW, THEREFORE, in consideration of the mutual covenants and promises set forth below, the parties agree as follows:

1. STATEMENT AND CERTIFICATION

1.1 Declaration. Declarant hereby declares and affirms, under penalty of perjury, that the written statement and any attachments submitted to Recipient and any statements made orally in the matter described above are true, correct, complete, and accurate to the best of Declarant's knowledge, information, and belief. Declarant's factual statement is provided below:

2. ACKNOWLEDGMENT OF CRIMINAL PENALTIES

2.1 Penalty Acknowledgment. Declarant acknowledges that knowingly making a false statement, swearing to a false statement, or submitting materially false documentation in a sworn instrument or affidavit may constitute perjury or other criminal offenses under applicable law and may subject Declarant to criminal prosecution, civil liability, fines, and imprisonment.

2.2 Materiality. Declarant understands that a misstatement or omission of material fact may be the basis for rescission of rights provided by Recipient and may be relied upon by law enforcement, regulatory authorities, or other governmental entities for investigative or prosecutorial purposes.

3. SCOPE, USE AND DISCLOSURE

3.1 Use and Reliance. Declarant expressly authorizes Recipient and its agents to rely upon the statements and documents provided and to disclose such statements and documents to third parties, including governmental authorities, as required or permitted by law or as reasonably necessary to investigate, adjudicate, or enforce rights relating to the matter described above.

3.2 Further Cooperation. Declarant agrees to cooperate fully with Recipient, including providing additional documents, affidavits, or testimony, if requested and within the Declarant's knowledge, to verify the matters certified herein.

4. REPRESENTATIONS, WARRANTIES AND INDEMNITY

4.1 Representations and Warranties. Declarant represents and warrants that (a) Declarant has the authority to make this Statement; (b) the facts set forth are true and correct; and (c) there are no material facts known to Declarant that have been omitted that would render this Statement misleading.

4.2 Indemnity. To the fullest extent permitted by law, Declarant shall defend, indemnify, and hold harmless Recipient and its officers, employees, and agents from and against any and all claims, losses, liabilities, costs and expenses (including reasonable attorneys' fees) arising out of or resulting from any false or negligent misrepresentation contained in this Statement.

5. NOTICES

All notices, requests, demands and other communications required or permitted under this Statement shall be in writing and shall be delivered to the addresses first set forth above or to such other address as either party may designate by written notice to the other.

6. AMENDMENTS, WAIVER, SEVERABILITY

6.1 Amendments and Waiver. No amendment or waiver of any provision of this Statement will be effective unless in writing and signed by both parties. No failure or delay by any party in exercising any right will operate as a waiver of that right.

6.2 Severability. If any provision of this Statement is held to be invalid, illegal or unenforceable by a court of competent jurisdiction, the remaining provisions will continue in full force and effect and the parties will negotiate in good faith to replace the invalid provision with a valid provision that most closely approximates the intent and economic effect of the invalid provision.

7. GOVERNING LAW; ENTIRE AGREEMENT

7.1 Governing Law. This Statement shall be governed by and construed in accordance with the laws of the State of without regard to its conflict of laws principles.

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

8. COUNTERPARTS

This Statement 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. Signatures transmitted by electronic means, including scanned images, shall be binding for all purposes.

CERTIFICATION

I, the undersigned Declarant, certify under penalty of perjury under the laws of the State of that the foregoing is true and correct to the best of my knowledge and belief. Executed on this date: .

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