Preliminary Affidavit Declaration

PRELIMINARY AFFIDAVIT DECLARATION

This Preliminary Affidavit Declaration is made on the date: by Affiant Name: (Affiant) and Receiving Party Name: . Venue/Jurisdiction: .

RECITALS

WHEREAS, Affiant is competent to testify to the matters set forth herein and has personal knowledge of the facts stated in this Preliminary Affidavit Declaration or believes them to be true based on investigation and records available to Affiant; and

WHEREAS, the facts described below are provided to preserve evidence, inform the Receiving Party, and support initial pleadings, motions, provisional relief, or administrative filings; and

WHEREAS, Affiant intends for this Preliminary Affidavit Declaration to be relied upon by counsel, the receiving party, and any tribunal as an initial sworn statement of material facts.

NOW, THEREFORE, in consideration of the foregoing and the mutual covenants herein, Affiant declares as follows:

1. AFFIANT IDENTIFICATION

Affiant is an individual or authorized representative of an entity: Individual Corporation Limited Liability Company Other

2. CASE / FILE IDENTIFICATION

3. STATEMENT OF FACTS

Affiant hereby states, under oath, the following material facts in chronological and narrative form. Each paragraph below contains facts known personally to Affiant or derived from business records kept in the ordinary course and which Affiant believes to be true and correct:

4. EXHIBITS AND SUPPORTING MATERIALS

Attached hereto and incorporated by reference are true and correct copies of documents and records relied upon by Affiant in forming the statements above. Each exhibit is labeled and described for identification.

5. REPRESENTATIONS

Affiant represents and warrants that: (a) Affiant has authority to execute this declaration; (b) the facts set forth herein are true and correct to the best of Affiant's knowledge and belief; (c) no material fact known to Affiant has been omitted that would make the statements herein misleading; and (d) Affiant will supplement or amend this declaration promptly if additional facts come to light.

6. OATH AND VERIFICATION

Affiant declares under penalty of perjury under the laws of the jurisdiction named above that the foregoing is true and correct. Affiant understands that a willfully false statement made in this declaration may subject Affiant to penalties for perjury and other sanctions permitted by law.

I declare under penalty of perjury that the foregoing is true and correct. Acknowledged

7. NOTICES

All notices, demands, and 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 a party may designate by written notice in accordance with this section.

8. AMENDMENTS, WAIVER, COUNTERPARTS

This declaration may be amended only by a written instrument signed by Affiant and the Receiving Party. No failure or delay by any party in exercising any right under this declaration shall operate as a waiver. This declaration may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one instrument.

9. GOVERNING LAW, ENTIRE AGREEMENT, SEVERABILITY

Governing Law: This declaration shall be governed by and construed in accordance with the laws of the jurisdiction stated in the opening paragraph, without regard to conflict of law principles.

Entire Agreement: This declaration, including any exhibits, constitutes the entire agreement of the parties with respect to the subject matter hereof and supersedes all prior oral or written statements.

Severability: If any provision of this declaration is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect to the extent permitted by law.

10. AUTHORITY TO EXECUTE

Each person signing below represents and warrants that they are authorized to execute this declaration on behalf of the party for whom they sign and that their signature binds such party to the terms hereof.

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