Legal Statement of Declaration

Legal Statement of Declaration

This Legal Statement of Declaration (the "Declaration") is made on this by Declarant Name: whose Address: , and Receiving Party Name: , whose Address: .

RECITALS

WHEREAS, Declarant has personal knowledge of certain facts and circumstances relating to the subject matter described below and is competent to make the statements contained in this Declaration;

WHEREAS, Receiving Party requires a written declaration for reliance in connection with administrative, contractual, investigatory, or other lawful purposes concerning: ; and

WHEREAS, Declarant elects to provide a sworn statement of facts and related assurances to Receiving Party under the terms set forth below.

NOW, THEREFORE, in consideration of the mutual undertakings contained herein, Declarant and Receiving Party agree as follows.

1. DEFINITIONS

For purposes of this Declaration: (a) "Declarant" means the individual or entity identified as Declarant Name; (b) "Receiving Party" means the individual or entity identified as Receiving Party Name; (c) "Effective Date" means the date set forth above; and (d) "Statement of Facts" means the factual narrative provided by Declarant in Section 2 below and any attachments incorporated by reference.

2. DECLARATION OF FACTS

Declarant hereby affirms, under penalty of perjury, that the following facts are true and within Declarant's personal knowledge unless stated otherwise. Declarant shall provide a clear, concise description of the relevant facts in the space below and may attach additional pages if necessary.

Declarant acknowledges that the Statement of Facts includes any material circumstances known to Declarant that would affect the Receiving Party's evaluation of the matters asserted herein, including dates, locations, names of witnesses, and documentary sources where applicable. Relevant date of the principal events:

3. REPRESENTATIONS AND WARRANTIES

Declarant represents and warrants that: (a) Declarant is competent to make this Declaration and has authority to assert the statements contained herein; (b) the Statement of Facts is true, complete, and accurate to the best of Declarant's knowledge and belief; (c) no material fact has been intentionally omitted; and (d) Declarant will promptly notify Receiving Party in writing of any subsequently discovered information that materially alters or corrects the Statement of Facts.

4. AUTHORIZED RELIANCE AND LIMITATION

Receiving Party may rely on this Declaration solely for the internal administrative, contractual, investigatory, or adjudicative purposes expressly stated by Receiving Party at the time of reliance. No other party shall acquire rights by virtue of this Declaration without the written consent of Declarant. This Declaration does not constitute a transfer of rights, a waiver of defenses, or an admission of liability unless expressly stated herein.

5. CONFIDENTIALITY

Unless otherwise indicated below, the Receiving Party shall treat the content of this Declaration as confidential and shall not disclose it to third parties except as required by law, court order, or regulation. If Declarant desires confidentiality, check the box and describe any required protective measures.

Confidentiality requested

6. INDEMNITY

Declarant agrees to indemnify, defend and hold harmless Receiving Party and its officers, directors, employees and agents from and against any and all losses, liabilities, damages, costs or expenses (including reasonable attorneys' fees) arising out of or resulting from (a) any material misrepresentation or omission in the Statement of Facts, or (b) any intentional false statement made by Declarant in connection with this Declaration.

7. REMEDIES; LIMITATION OF LIABILITY

Receiving Party's remedies for breach of this Declaration shall include all available equitable and legal remedies. Except in cases of willful misconduct or gross negligence, neither party shall be liable to the other for consequential, incidental, punitive, or special damages arising from this Declaration.

8. NOTICES

All notices, requests, demands and other communications required or permitted under this Declaration shall be in writing and delivered to the addresses set forth below or to such other address as either party may designate by written notice to the other party in accordance with this Section.

9. AMENDMENT; WAIVER; COUNTERPARTS

This Declaration may be amended only by a written instrument signed by both parties. No waiver of any breach or default shall be deemed a waiver of any other right or of any subsequent breach. This Declaration may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. Facsimile and electronic signatures shall be effective to bind the signatories.

10. GOVERNING LAW; VENUE

This Declaration shall be governed by and construed in accordance with the laws of the State of , without regard to conflicts of law principles. The parties submit to the exclusive jurisdiction of the state and federal courts located in that State for any action arising under or relating to this Declaration.

11. ENTIRE AGREEMENT; SEVERABILITY

This Declaration, together with any attachments and written amendments, constitutes the entire agreement between the parties concerning the subject matter hereof and supersedes all prior oral and written communications, understandings, and agreements with respect thereto. If any provision of this Declaration is held to be invalid or unenforceable, the remainder of this Declaration shall remain in full force and effect and the invalid or unenforceable provision shall be deemed modified to the minimum extent necessary to make it enforceable.

12. CERTIFICATION

Declarant certifies under penalty of perjury under the laws of the State of that the foregoing is true and correct to the best of Declarant's knowledge.

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