Legal Surrender Request Form

LEGAL SURRENDER REQUEST FORM

This Legal Surrender Request Form is submitted by Requestor Name: with address: (the "Requestor"), to Holder Name: with address: (the "Holder"), on Date Submitted: .

RECITALS

WHEREAS, Requestor is the record or beneficial owner of certain asset(s), account(s), license(s), or rights described below that Requestor seeks to surrender, transfer, or relinquish to Holder; and

WHEREAS, Holder currently holds custody, control, record title, or administrative responsibility for the subject asset(s) and has the authority to accept and effectuate the surrender upon the terms set forth herein; and

WHEREAS, the parties wish to document the Requestor's request for surrender and the terms upon which Holder may accept such surrender.

NOW THEREFORE, in consideration of the mutual covenants and agreements set forth below, and for other good and valuable consideration, the sufficiency of which is acknowledged, the parties agree as follows:

1. DEFINITIONS

1.1 "Surrendered Assets" means the asset(s), account(s), license(s), certificate(s), document(s), or legal right(s) identified in Section 2 and any related claims, rights to proceeds, and ancillary materials transferred or delivered pursuant to this Form.

2. DESCRIPTION OF SURRENDER

2.1 Type of surrender (check all that apply): Property Account License/Permit Security Interest/Collateral Other

3. REQUEST TO SURRENDER; METHOD OF TRANSFER

3.1 Requestor hereby unconditionally requests that Holder accept surrender of the Surrendered Assets described above and deliver, transfer or record such assets or titles in accordance with Holder's standard procedures and the terms of this Form. Requestor instructs Holder to transfer or record as follows:

3.2 Requested effective date of surrender: . Holder's acceptance of this request is evidenced only by Holder's signature below or other written acknowledgement.

4. REPRESENTATIONS AND WARRANTIES

4.1 Requestor represents and warrants that Requestor has full authority, good and marketable title, and legal right to surrender the Surrendered Assets; no other person or entity has an outstanding claim, lien, or encumbrance except as expressly disclosed in writing to Holder; and all information provided in this Form is true, accurate and complete in all material respects.

4.2 Holder represents that it will act in accordance with applicable laws and its internal procedures when effecting surrender, and that Holder's acceptance is conditioned upon verification of Requestor's authority and, if required, receipt of originals or authenticated copies of documents identified herein.

5. RELEASE, INDEMNITY AND LIABILITY

5.1 Upon Holder's acceptance and delivery of the Surrendered Assets in accordance with this Form, Requestor shall be deemed to have released Holder from further obligations with respect to the Surrendered Assets, except for any liability resulting from Holder's willful misconduct or gross negligence.

5.2 Requestor shall indemnify, defend and hold Holder harmless from and against any and all losses, liabilities, claims, damages, costs and expenses (including reasonable attorneys' fees) arising out of any breach of Requestor's representations or any misstatement or omission in this Form.

6. CONSIDERATION

6.1 The parties acknowledge and agree that the consideration for this surrender is the mutual covenants contained herein and any additional consideration specified below: Amount or terms (if any):

7. ACCEPTANCE; EFFECTIVENESS

7.1 This Request becomes effective only upon Holder's written acceptance or signature below. Holder may, in its discretion, refuse acceptance if Holder determines that requirements for transfer, recordation, cancellation, or legal compliance have not been satisfied.

8. NOTICES

All notices, demands or communications required or permitted hereunder shall be in writing and delivered to the addresses set forth below. Notice is effective upon personal delivery or three business days after deposit in the mail, postage prepaid, to the address indicated.

9. AMENDMENT; WAIVER; COUNTERPARTS

9.1 No amendment or waiver of any provision of this Form shall be effective unless in writing and signed by both parties. No failure or delay by any party in exercising any right shall operate as a waiver.

9.2 This Form 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. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

10.1 Governing Law. This Form shall be governed by and construed in accordance with the laws of the jurisdiction indicated for choice of law: , without regard to its conflicts of law rules.

10.2 Entire Agreement. This Form constitutes the entire agreement between the parties concerning the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings and communications, whether written or oral.

10.3 Severability. If any provision of this Form is held to be invalid or unenforceable in any respect, the validity and enforceability of the remaining provisions shall not be affected.

11. ADDITIONAL ADMINISTRATIVE DETAILS

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