Legal Residency Declaration

LEGAL RESIDENCY DECLARATION

This Legal Residency Declaration is entered into by and between Declarant Name: and Recipient Name: . Declarant Date of Birth: . This Declaration is effective as of Effective Date: .

RECITALS

WHEREAS, Declarant maintains a primary residence at Address: and attests that the residence is the location of Declarant's true, fixed, and permanent home (domicile); and

WHEREAS, Recipient requires a written declaration of residency to determine eligibility, enrollment, benefits, or other legal status, and Declarant possesses personal knowledge of the facts stated in this Declaration; and

WHEREAS, Declarant is willing to provide this Declaration and the supporting documentation described below under penalty of perjury for the purposes set forth by Recipient.

NOW THEREFORE

In consideration of the foregoing recitals and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. DECLARATION OF RESIDENCY

1.1 Declarant hereby affirms, represents and warrants that Declarant has been physically present and has maintained residency at the address set forth above for the period beginning on and continuing through , except as may be disclosed in writing to Recipient pursuant to Section 4.

1.2 Declarant declares under penalty of perjury that the address identified is Declarant's primary and legal domicile, and that Declarant intends to remain at that address as Declarant's permanent home unless and until Declarant executes a subsequent written declaration stating otherwise.

2. SUPPORTING DOCUMENTATION

2.1 Declarant shall provide copies of at least two (2) of the following documents as contemporaneous corroboration of residency. Declarant certifies that each selected document is true, accurate, and relates to the Declarant named herein:

State or federal identification card

Utility bill showing Declarant's name and address

Lease or rental agreement

Tax return or official government correspondence

Other supporting documentation (describe):

3. REPRESENTATIONS AND WARRANTIES

Declarant represents and warrants that: (a) the information contained in this Declaration is true and correct to the best of Declarant's knowledge; (b) Declarant has the authority to execute this Declaration; (c) Declarant will promptly notify Recipient in writing if Declarant's residency status changes; and (d) Declarant understands that intentional falsification of residency information may subject Declarant to administrative denial of benefits and civil or criminal penalties.

4. NOTICE OF CHANGE IN RESIDENCY

Declarant shall provide written notice to Recipient within fifteen (15) days of any change in Declarant's primary address or domicile. Notices shall be delivered to the addresses set forth in Section 10 (Notices) in accordance with the delivery provisions therein.

5. CONFIDENTIALITY AND USE OF INFORMATION

Recipient shall use the information and supporting documents provided under this Declaration solely for the purpose of verifying Declarant's residency for the specific purpose stated in the opening paragraph. Recipient shall maintain such records in accordance with its internal confidentiality policies and applicable law.

6. REMEDIES AND INDEMNIFICATION

Declarant agrees to indemnify and hold harmless Recipient and its officers, employees, and agents from any claims, losses, damages, liabilities, costs, or expenses (including reasonable attorneys' fees) arising out of a material misrepresentation in this Declaration or the submission of forged or fraudulent supporting documents.

7. NOTICES

All notices required under this Declaration shall be in writing and delivered by hand, certified mail (return receipt requested), or other nationally recognized overnight delivery service to the following addresses unless otherwise designated in writing:

8. AMENDMENT AND WAIVER

This Declaration may be amended only by a written instrument signed by both parties. No waiver of any provision hereof shall be effective unless in writing and signed by the party granting the waiver.

9. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

9.1 Governing Law. This Declaration shall be governed by and construed in accordance with the laws of the state where the Declarant's residence is located, without regard to conflict of law principles.

9.2 Severability. If any provision of this Declaration is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect and the invalid provision shall be reformed to the extent necessary to effectuate the parties' intent.

9.3 Entire Agreement. This Declaration, together with any exhibits or attachments executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written.

10. MISCELLANEOUS

10.1 Counterparts. This Declaration 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.

10.2 Execution. The person executing this Declaration on behalf of each party represents and warrants that they have full authority to bind the party for whom they sign.

ADDITIONAL FACTS

CERTIFICATION

I certify under penalty of perjury under the laws of the governing jurisdiction that the foregoing is true and correct and that I am the person identified as Declarant in this Declaration. I understand that making a false statement may subject me to civil or criminal penalties.

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