Legal Residency Certification

LEGAL RESIDENCY CERTIFICATION

This Legal Residency Certification (the "Certification") is made effective as of by and between Certifying Entity Name: with principal address , and Resident Name: with principal residence address .

RECITALS

WHEREAS, the Resident seeks formal certification of legal residency from the Certifying Entity for purposes of establishing residency status with public or private institutions, and the Certifying Entity has authority to provide such certification under its policies and applicable law; and

WHEREAS, the Resident represents that the Resident has maintained a primary place of abode and has met residency criteria for the period beginning through ; and

WHEREAS, the Resident has submitted or will submit documentation to substantiate residency and the Certifying Entity requires written certification under penalty of perjury prior to issuing formal confirmation.

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

1. DEFINITIONS

For purposes of this Certification: "Residency" means the factual and legal status of domiciliary or lawful residence at a principal address; "Documentation" means authentic records or copies demonstrating residency (including but not limited to government-issued identification, utility bills, lease agreements, tax returns, or voter registration); "Effective Date" means the date set forth above.

2. RESIDENT CERTIFICATION

The Resident hereby certifies, under penalty of perjury, that to the best of the Resident's knowledge and belief: (a) the Resident's principal residence is as set forth above; (b) the Resident has been physically present and has had the intent to remain at that residence for the period specified; and (c) the statements made and the documents provided in support of residency are true, accurate and complete.

Resident attests to the following criteria (check all that apply):

Physical presence at the stated address for the residency period.

Present intent to make the stated address the Resident's principal and permanent home.

Financial or tax filings, employment, or other indicia that corroborate residency.

3. VERIFICATION AND DOCUMENTS

The Resident shall provide the following documents to enable verification. The Certifying Entity may request certified copies or original documents where necessary. List of provided documents:

Identification used for verification (type and number):

Check the documents submitted (check all that apply):

Driver's license or state ID

Utility bill or billing statement

Lease or rental agreement

Tax return or governmental correspondence

4. CERTIFYING ENTITY OBLIGATIONS

Upon satisfactory review of the Documentation, the Certifying Entity shall issue a written certification stating that the Certifying Entity has verified, to the extent feasible and consistent with its procedures, that the Resident is a legal resident for the period specified. The Certifying Entity's certification shall be limited to the facts the Certifying Entity has actually verified and shall not constitute a legal determination of residency for purposes outside the Certifying Entity's authority.

5. CONFIDENTIALITY AND USE OF INFORMATION

The Certifying Entity shall use the Documentation and any personal information provided by the Resident solely for the purpose of verifying residency and preparing the Certification. The Certifying Entity shall maintain reasonable administrative and technical safeguards to protect personal information in its possession and shall not disclose such information except as required by law or with the express written consent of the Resident.

6. REPRESENTATIONS, WARRANTIES AND INDEMNIFICATION

Each party represents and warrants that it has authority to enter into this Certification. The Resident represents that all statements and documents provided are true and complete. The Resident shall indemnify and hold harmless the Certifying Entity from and against any losses, claims, liabilities or expenses arising from any false or fraudulent statement or omission by the Resident in connection with this Certification.

7. REMEDIES

Remedies available to the Certifying Entity for breach by the Resident include denial or revocation of certification, recovery of costs incurred in verification, and any other remedies available at law or in equity. The exercise of any remedy shall not preclude the exercise of any other remedy.

8. NOTICES

Notices to Certifying Entity:

Notices to Resident:

Notices shall be effective upon personal delivery, or three (3) days after deposit in the United States mail, postage prepaid, or upon confirmed electronic transmission if sent to an address expressly agreed in writing by the receiving party.

9. AMENDMENTS; WAIVER

No amendment, waiver or modification of any provision of this Certification shall be effective unless in a written instrument signed by both parties. No failure or delay by either party in exercising any right shall operate as a waiver of that right.

10. GOVERNING LAW

This Certification shall be governed by and construed in accordance with the laws of the state of , without regard to its conflicts of laws principles.

11. ENTIRE AGREEMENT

This Certification constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations and understandings of the parties, whether written or oral.

12. SEVERABILITY

If any provision of this Certification is determined to be invalid or unenforceable under applicable law, such provision shall be ineffective only to the extent of such invalidity or unenforceability, and the remaining provisions shall remain in full force and effect.

13. COUNTERPARTS; ELECTRONIC SIGNATURES

This Certification may be executed in one or more counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Signatures delivered by electronic means shall be deemed original signatures for all purposes.

Execution

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