Lodgment Declaration Form

LOD GMENT DECLARATION FORM

Lodger Name:

Recipient Name:

RECITALS

WHEREAS, Lodger represents that it intends to deliver, deposit or otherwise lodge certain documents, materials or goods (the "Lodged Items") with Recipient for the limited purposes and scope described below; and

WHEREAS, Recipient agrees to accept lodgment of the Lodged Items under the terms, conditions and limitations set forth in this Lodgment Declaration Form and acknowledges receipt and safekeeping obligations as described herein; and

WHEREAS, the parties intend for this Lodgment Declaration Form to constitute a binding agreement governing the handling, access, retention, return and any applicable fees related to the Lodged Items.

DECLARATION OF LODGMENT

Description of Lodged Items:

Purpose of Lodgment:

SCOPE OF LODGMENT

PAYMENT TERMS

Lodgment Fee (total):

Late Payment Fee (if unpaid after due date):

TERM AND TERMINATION

Commencement Date:

Anticipated Termination / Retrieval Date:

Notice Period for Termination (days):

Upon termination or expiration, Recipient shall return or dispose of the Lodged Items in accordance with Lodger's written instructions. Absent instructions, Recipient may retain items for a commercially reasonable time and thereafter treat as unclaimed property under applicable law.

CONFIDENTIALITY

Recipient acknowledges that certain Lodged Items may contain Confidential Information. Recipient agrees to protect such Confidential Information from unauthorized disclosure, to use it only as necessary to perform its obligations under this Lodgment Declaration Form, and to implement reasonable safeguards at least equivalent to those used to protect Recipient's own confidential material.

Confidential Information does not include information that: (a) is or becomes public through no breach by Recipient; (b) is received from a third party without breach of any obligation of confidentiality; or (c) is independently developed by Recipient without use of Lodger's Confidential Information.

I acknowledge and agree to the confidentiality terms above.

COMPLIANCE; LIABILITY

Each party shall comply with all applicable laws and regulations in the performance of this Lodgment Declaration Form. Recipient accepts lodgment solely on the representations made by Lodger and is not responsible for verifying the truth, completeness or legality of the Lodged Items except as may be required by applicable law.

Except for willful misconduct or gross negligence, Recipient's liability for loss or damage to Lodged Items shall be limited to the lodgment fee actually paid for the relevant item(s) or, if stated in separate written schedule, to the declared value for those items.

GOVERNING LAW

This Lodgment Declaration Form shall be governed by and construed in accordance with the laws of the jurisdiction identified below, without regard to conflict of law principles.

Governing Jurisdiction:

ENTIRE AGREEMENT

This Lodgment Declaration Form, together with any attached schedules and written instructions delivered by Lodger and accepted by Recipient, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, representations, understandings and agreements, whether oral or written. Any amendment must be in writing and signed by both parties.

DECLARATION AND CERTIFICATION

By signing below, Lodger certifies that it is authorized to lodge the described items and that the information provided in this form is true and complete. Recipient certifies that it accepts lodgment under the terms of this Lodgment Declaration Form and will maintain custody and control of the Lodged Items in accordance with the terms herein.

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