Legal Statement Form

LEGAL STATEMENT FORM

This Legal Statement Form (the "Statement") is executed on by and between Declarant Name: of and Recipient Name: of .

RECITALS

WHEREAS, Declarant possesses certain knowledge, information, and facts relating to the matter identified as Statement Reference Number: and concerning an event occurring on or about at or near .

WHEREAS, Recipient has requested a written statement from Declarant for purposes of documentation, investigation, or other legitimate reliance as further described herein.

WHEREAS, the parties intend that this Statement provide a complete and accurate recitation of the facts known to Declarant at the time of signing and that Recipient may rely thereon in accordance with the terms set forth below.

NOW, THEREFORE

In consideration of the mutual promises contained in this Statement and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. STATEMENT OF FACTS

Declarant hereby sets forth, under penalty of perjury as provided below, the following factual statements which Declarant affirms to be true and correct to the best of Declarant's knowledge, information, and belief as of the date of this Statement. Provide a clear, chronological description of the facts, persons involved, actions taken, and any other details material to the matter.

2. ATTACHMENTS AND EVIDENCE

Declarant attaches, identifies, or will provide documents, photographs, recordings, or other exhibits listed below that form part of this Statement and that are relied upon to support the factual assertions herein.

3. REPRESENTATIONS AND WARRANTIES

Declarant represents and warrants to Recipient that: (a) Declarant has personal knowledge of the matters stated herein or has identified the source of the information; (b) the facts set forth in this Statement are true, complete and correct as of the date hereof to the best of Declarant's knowledge, information and belief; and (c) Declarant has the authority to make this Statement and to bind Declarant to the covenants herein.

4. OATH, CERTIFICATION, AND PENALTY CLAUSE

By executing this Statement, Declarant certifies under penalty of perjury that the foregoing is true and correct. Declarant understands that knowingly making a false statement in a written legal statement may subject Declarant to civil and criminal penalties, including but not limited to penalties for perjury under applicable law.

5. CONFIDENTIALITY

Unless otherwise required by law, the parties agree that the content of this Statement, and any attachments hereto designated as confidential, shall be treated as confidential by Recipient and shall not be disclosed except (i) to advisors, counsel, or insurers on a need-to-know basis and subject to confidentiality obligations, (ii) as required by court order or statute, or (iii) with the prior written consent of Declarant.

6. USE, RELIANCE, AND LIMITATION OF LIABILITY

Recipient may rely on the factual assertions contained in this Statement only for the purposes expressly stated in this document. Recipient acknowledges that Recipient's use of this Statement is subject to the limitations set forth herein, and Declarant disclaims liability for third-party reliance except as expressly provided by applicable law.

7. INDEMNIFICATION

Declarant agrees to indemnify, defend and hold harmless Recipient and its officers, directors, agents, employees, and representatives from and against any losses, liabilities, damages, costs and expenses (including reasonable attorneys' fees) arising out of any third-party claims resulting from Declarant's intentional misrepresentation or material omission in this Statement.

8. NOTICES

Any formal notice required under this Statement shall be in writing and delivered personally or sent by certified mail, return receipt requested, or by an overnight courier service to the addresses provided below or such other addresses as the parties may designate in writing.

9. GOVERNING LAW

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

10. ENTIRE AGREEMENT

This Statement constitutes the entire agreement and understanding between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous statements, understandings, negotiations, and agreements, whether written or oral, relating thereto.

11. SEVERABILITY

If any provision of this Statement is held to be invalid, illegal or unenforceable in any respect, the remaining provisions shall remain in full force and effect and shall be construed so as to effectuate the original intent of the parties to the fullest extent permitted by law.

12. AMENDMENTS, WAIVER, AND COUNTERPARTS

No amendment or waiver of any provision of this Statement shall be effective unless made in a written instrument signed by both parties. The failure of either party to enforce any right shall not constitute a waiver of that or any other right. This Statement may be executed in counterparts, each of which shall constitute an original and all of which together shall constitute one and the same instrument.

ADDITIONAL DECLARATIONS

By signing below, Declarant certifies the truthfulness and completeness of the information contained in this Statement and acknowledges the foregoing representations, warranties, and indemnities. Recipient acknowledges receipt of this Statement and its right to rely on the statement subject to the terms herein.

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