Miscellaneous Self-Declaration Form

MISCELLANEOUS SELF-DECLARATION FORM AND SERVICES AGREEMENT

Parties and Identifying Information

Declarant Name:

Recipient Name:

Recitals

WHEREAS, the Declarant represents that Declarant has been requested to provide certain services and/or information to the Recipient and to make factual declarations regarding the Declarant's status and acts; and

WHEREAS, the parties desire to set forth the scope of the services and the representations and warranties of the Declarant and to memorialize mutual obligations, confidentiality, and payment terms as set forth below; and

WHEREAS, the parties intend that the statements contained in this Self-Declaration be relied upon by the Recipient in connection with the services described and any related decision-making;

Scope of Work

Describe the services, deliverables, or facts being declared. Include clear, measurable tasks and deadlines where applicable.

Self-Declaration and Representations

The Declarant hereby declares, represents and warrants under penalty of perjury where applicable that the following statements are true and correct to the best of Declarant's knowledge:

I affirm that the factual statements and supporting documents provided are true, accurate, and complete.

I have no undisclosed conflicts of interest that would materially affect the performance of the services or the truth of this declaration.

I will comply with applicable laws, regulations, and contractual obligations in performing any services described herein.

Attachments and Evidence

List or attach all documents, exhibits, or other evidence supporting this declaration. Each listed item should be labeled and referenced in the Scope of Work where applicable.

Payment Terms

Total Payment Amount: $

Late Payment Fee: (applies to overdue amounts)

Term and Termination

Commencement Date:   Termination Date/Estimate:

Either party may terminate this Agreement for convenience upon written notice of days. Immediate termination may occur for material breach, insolvency, or unlawful conduct, subject to any cure periods expressly set forth in this Agreement.

Confidentiality

The parties agree that all non-public information disclosed by either party in connection with this Agreement is confidential. The receiving party shall: (a) use confidential information solely for the performance and evaluation of the services; (b) restrict disclosure to employees, agents, or contractors who have a need to know and who are bound to confidentiality obligations; and (c) implement reasonable safeguards to protect confidential information from unauthorized use or disclosure.

Exceptions: Confidentiality obligations do not apply to information that is (i) publicly known through no breach by the receiving party, (ii) independently developed without reference to the disclosing party's confidential information, or (iii) required to be disclosed by law or valid process, provided the disclosing party gives prompt notice to the other to seek protective measures.

Indemnification and Remedies

The Declarant agrees to indemnify, defend and hold harmless the Recipient from any third-party claims, liabilities, losses, or expenses arising from the Declarant's breach of this declaration, negligence, willful misconduct, or misrepresentations. Remedies provided in this Agreement are cumulative and in addition to any other legal or equitable remedies.

Governing Law and Jurisdiction

This Agreement shall be governed by and construed in accordance with the laws of the state of without regard to conflict of laws principles. The parties submit to the exclusive jurisdiction of the courts located in that state for resolution of disputes arising under this Agreement.

Entire Agreement; Severability

This document, including any attachments and referenced exhibits, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior negotiations, understandings, and agreements. If any provision of this Agreement is held invalid or unenforceable, the remainder of the Agreement shall remain in full force and effect.

Certification and Acknowledgment

By signing below, the Declarant certifies under penalty of law that the information provided in this Self-Declaration Form is true, complete, and correct to the best of Declarant's knowledge. Declarant understands that knowingly providing false information may subject Declarant to civil or criminal penalties.

Notices

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses provided above, or to such other address as a party may designate by written notice. Notices are effective upon receipt.

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