Legal Prefiling Statement

LEGAL PREFILING STATEMENT

This Legal Prefiling Statement is executed on by Claimant Name: , with primary contact at , and Respondent Name: , with primary contact at .

RECITALS

WHEREAS, Claimant asserts that certain claims exist against Respondent arising from facts described herein and seeks to provide notice of intention to pursue legal remedies if the matter is not resolved by administrative or prelitigation means;

WHEREAS, the parties intend to document the prefiling steps, attempts to resolve the dispute, and the relief sought in order to comply with any contractual or jurisdictional prelitigation prerequisites and to preserve evidence and privileges pertinent to the dispute;

WHEREAS, the parties acknowledge that this Statement is not a pleading but is intended to be an accurate summary of prefiling efforts and claims as of the date set forth above.

NOW, THEREFORE

In consideration of the mutual acknowledgments contained herein, and intending to be legally bound, the parties state as follows:

1. DEFINITIONS

For purposes of this Statement, the following definitions apply: "Claim" means any asserted cause of action, demand for relief, or remedy described in Section 3; "Prefiling Requirements" means contractual, statutory, or administrative prerequisites to filing an action, including but not limited to notice, cure periods, administrative exhaustion, or mandatory negotiations; "Effective Date" means the statement_date provided above.

2. PARTIES AND REPRESENTATION

Claimant is identified above. Claimant entity type: Individual Corporation Limited Liability Company Other

Respondent is identified above. Respondent entity type: Individual Corporation Limited Liability Company Other

3. SUMMARY OF CLAIMS AND FACTUAL BASIS

Claimant alleges the following causes of action as of the Effective Date and provides the factual basis supporting each asserted claim. Summaries below are intended to preserve the substance of the claim and may be supplemented when filing a pleading.

4. RELIEF SOUGHT

Claimant presently seeks the following relief. The listing of relief below is a non-exhaustive statement of the remedies Claimant may pursue in an appropriate forum.

5. PREFILING AND ADMINISTRATIVE STEPS TAKEN

The parties certify the following prefiling steps were taken. Check all that apply and provide supporting dates where indicated.

Demand letter sent: Yes Date sent:

Administrative claim filed: Yes Agency or forum: Date filed:

Demand for alternative dispute resolution (mediation/arbitration): Requested Method proposed: Proposed date (if any):

6. ATTACHMENTS AND EVIDENCE

The following documents are identified as attachments to this Statement and are asserted to be relevant evidence supporting the claims and prefiling steps described above.

Attachments included with this Statement: Yes If not included, indicate where stored or how to obtain:

7. CONFIDENTIALITY, PRIVILEGE, AND PRESERVATION OF EVIDENCE

The parties acknowledge that communications made in connection with settlement negotiations, mediation, or otherwise designated as confidential are intended to remain privileged or protected where applicable under governing law. Each party shall preserve relevant evidence and shall take reasonable steps to prevent spoliation of documents, electronic data, and other materials relevant to the matters described in this Statement.

8. CERTIFICATION

By signing below, the signatory certifies under penalty of perjury that to the best of the signatory's knowledge, information, and belief formed after a reasonable inquiry, the statements made in this Legal Prefiling Statement are true and complete, that the signatory is authorized to execute this Statement on behalf of the party identified, and that all material prefiling steps known to the signatory at the time of execution are disclosed herein.

Certification of accuracy: I certify the foregoing

9. NOTICES

Notices under this Statement shall be given in writing to the addresses specified below or to such other address as a party may designate in writing in accordance with this Section. Notice is effective upon receipt.

10. MISCELLANEOUS PROVISIONS

Governing Law: This Statement shall be governed by and construed in accordance with the substantive laws of the state identified below without regard to conflict of law principles.

Choice of law state:

Entire Agreement: This Statement constitutes the entire written statement of the parties' prefiling representations and supersedes any prior written statements regarding the matters set forth herein.

Severability: If any provision of this Statement is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect and shall be interpreted so as to effect the original intent of the parties as closely as possible.

Amendments; Waiver; Counterparts: This Statement may be amended only by a written instrument executed by the parties. No waiver of any term shall be effective except in writing. This Statement may be executed in counterparts, each of which shall be an original and all of which together shall constitute one instrument.

11. SIGNATURES

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