Legal Self-Attestation Form

LEGAL SELF-ATTESTATION FORM

This Legal Self-Attestation Form is made on this day of , between Attestor Name: (the "Attestor") and Verifier Name: (the "Verifier").

RECITALS

WHEREAS, the Attestor is required to provide a written attestation to the Verifier in connection with certain determinations, compliance reviews, or eligibility assessments conducted by the Verifier; and

WHEREAS, the Attestor affirms under penalty of law that the factual statements set forth in this form are true, complete, and accurate to the best of the Attestor's knowledge and belief; and

WHEREAS, the Verifier requires the Attestor's written certification and consent to verify documents, records, or other supporting materials supplied in support of the Attestation.

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

1. DEFINITIONS

For purposes of this Form, the following terms shall have the meanings set forth below: "Attestation" means the statements and selections made by the Attestor in Section 2 below; "Supporting Documents" means any documentary evidence submitted or made available by the Attestor to substantiate the Attestation; and "Effective Date" means the date set forth in the opening paragraph of this Form.

2. ATTESTATION

The Attestor hereby attests, represents, and warrants to the Verifier that the following statements are true and correct as of the Effective Date (select applicable statements and provide supporting detail where requested):

Individual Corporation Limited Liability Company (LLC) Partnership Other:

I am the person or authorized representative of the entity identified above and hereby certify my identity and authority to execute this Attestation.

All information provided and all Supporting Documents submitted to the Verifier are true, complete, and accurate to the best of my knowledge and belief.

There have been no material changes to the facts attested to since the date of any Supporting Documents provided, except as described in the attached explanation.

3. REPRESENTATIONS AND WARRANTIES

The Attestor represents and warrants that (a) it has full authority to make the Attestation and to provide the Supporting Documents; (b) the Attestation is made voluntarily and without duress; (c) no material information has been knowingly omitted; and (d) the Attestor will promptly notify the Verifier in writing if any representation herein becomes inaccurate or incomplete.

4. ACKNOWLEDGMENT OF PENALTIES

The Attestor acknowledges that making a false statement, misrepresentation, or omission in this Attestation may subject the Attestor to civil and/or criminal penalties under applicable law, including penalties for perjury where applicable. The Attestor further acknowledges that the Verifier may rely on this Attestation in connection with rights, benefits, or legal obligations.

5. VERIFICATION AUTHORIZATION

The Attestor authorizes the Verifier to review, inspect, and copy any Supporting Documents and to communicate with relevant third parties, agencies, or custodians of record to verify the facts attested herein. Such verification may include contacting employers, financial institutions, government agencies, or other entities as necessary for verification purposes.

6. INDEMNIFICATION

The Attestor agrees to indemnify, defend, and hold harmless the Verifier and its officers, directors, agents, and employees from and against any and all claims, liabilities, losses, costs, and expenses (including reasonable attorneys' fees) arising out of or resulting from any breach of the representations, warranties, or attestations contained in this Form or from any negligent or willful misrepresentation by the Attestor.

7. REMEDIES

Remedies available to the Verifier for breach of this Attestation include, but are not limited to, rejection of the Attestation, rescission of any reliance-based determinations, administrative or legal proceedings, pursuit of damages, and notification to appropriate authorities. The exercise of any remedy shall not preclude the exercise of any other remedy available at law or in equity.

8. NOTICES

All notices or communications required or permitted under this Form must be in writing and delivered to the addresses set forth below or to such other address as either party may designate in writing in accordance with this section. Notices shall be deemed effective upon receipt.

9. GOVERNING LAW

This Form shall be governed by and construed in accordance with the laws of the jurisdiction specified by the parties below. To the extent the parties do not specify a different jurisdiction, the governing law shall be the law of the state in which the Verifier maintains its principal place of business.

Governing Law State:

10. ENTIRE AGREEMENT

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

11. SEVERABILITY

If any provision of this Form is held to be invalid, illegal, or unenforceable in any respect, such provision shall be severed, and the remaining provisions shall continue in full force and effect to the maximum extent permitted by law.

12. AMENDMENTS AND WAIVER

No amendment, modification, or waiver of any provision of this Form shall be effective unless made in writing and signed by both parties. The failure of either party to enforce any right or remedy under this Form shall not be deemed a waiver of any other right or remedy.

13. COUNTERPARTS

This Form 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.

14. CERTIFICATION

By signing below, the Attestor certifies under penalties of perjury that the information provided in this Legal Self-Attestation Form is true, correct, and complete. The Attestor further certifies that he or she is authorized to make the statements contained herein on behalf of the entity identified (if applicable).

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