Legal Questionnaire

LEGAL QUESTIONNAIRE

This Legal Questionnaire (the "Questionnaire") is made and entered into by and between Client Name: and Requesting Party Name: effective Date: .

Recitals

WHEREAS, the Requesting Party requires certain factual, documentary and background information relating to a legal matter; and

WHEREAS, the Client agrees to provide reasonably requested information in writing and to certify the accuracy of such information for use in assessment, negotiation, litigation preparation or regulatory proceedings; and

WHEREAS, the parties desire to set forth the manner, scope and legal terms governing the collection, use and certification of such information.

NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

1. Definitions

In this Questionnaire: "Questionnaire" means this instrument and any attachments; "Client" means the person or entity identified as Client Name; "Requesting Party" means the person or entity identified as Requesting Party Name; "Confidential Information" means information marked or reasonably understood to be confidential, including privileged communications and work product, but excluding information that becomes publicly available other than through breach of this Questionnaire.

2. Instructions for Completion

The Client shall answer each question fully and truthfully based on the Client's knowledge, belief and reasonable investigation. If a question is not applicable, mark "Not Applicable" and provide a brief explanation in the space provided. Supplemental pages may be attached and must be labeled with the question number to which they relate.

3. Information Requested

Corporation    Limited Liability Company    Partnership    Individual    Other (specify below)

Yes    No

4. Confidentiality and Use

All information provided in response to this Questionnaire shall be treated by the Requesting Party as Confidential Information. The Requesting Party shall not disclose Confidential Information except (a) to its counsel, experts and agents on a need-to-know basis for the Matter, (b) as required by applicable law or court order, or (c) as otherwise agreed in writing by the Client. The disclosure of information designated as privileged or work product shall not constitute a waiver of any privilege or protection, and the parties shall comply with applicable rules governing inadvertent disclosure.

5. Representations and Certifications

The Client represents and certifies that the information provided in this Questionnaire is true, accurate and complete to the best of the Client's knowledge, information and belief after reasonable inquiry. The Client further certifies that it has authority to provide the information and to authorize disclosure of non-privileged records to the Requesting Party as described herein.

6. Authorization to Obtain Records

The Client authorizes the Requesting Party, and its authorized agents and representatives, to obtain and review records, documents and information from third parties reasonably necessary for the Matter, including but not limited to financial institutions, insurers, employers and government agencies. This authorization is limited to non-privileged records and does not waive any applicable privilege.

Authorization granted: Yes    No

7. Notices

All notices and requests required or permitted under this Questionnaire shall be in writing and delivered to the addresses provided below. Notice is effective upon receipt.

8. Miscellaneous Provisions

Governing Law: This Questionnaire shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of laws principles.

Entire Agreement: This Questionnaire constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior agreements and understandings, whether written or oral, relating to such subject matter.

Severability: If any provision of this Questionnaire is held invalid or unenforceable, the remaining provisions shall remain in full force and effect and the invalid provision shall be reformed to the extent necessary to make it enforceable while preserving the parties' intent.

Amendments; Waiver: Any amendment to this Questionnaire must be in writing and signed by both parties. No failure or delay by either party in exercising any right shall operate as a waiver of that right.

Counterparts: This Questionnaire 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 imaging shall be effective for all purposes.

Sign Now