Relationship Disclosure Form

RELATIONSHIP DISCLOSURE FORM

Parties

First Party Name:

Second Party Name:

Recitals

WHEREAS, the First Party and the Second Party desire to identify and disclose any personal, financial or business relationships or affiliations that may give rise to a conflict of interest or influence the performance of services or obligations under any agreement between them; and

WHEREAS, the parties seek to set forth the scope, disclosures, mitigation measures, and contractual protections applicable to any disclosed relationship to ensure transparent and lawful dealings; and

WHEREAS, the parties intend for this Relationship Disclosure Form to be relied upon by each party and incorporated into any related business agreement to the extent provided herein.

Disclosure of Relationship

The parties hereby disclose the existence and nature of the relationship(s) described below. Each party affirms that the information provided is complete and accurate to the best of its knowledge. Check all that apply:

Scope of Work

The parties acknowledge that any services, deliverables or obligations performed in connection with the disclosed relationship shall be governed by the terms set forth below and in any separate agreement. Provide a concise description of the scope of work or engagement to which this disclosure relates.

Payment Terms

The parties shall specify any consideration exchanged in connection with the engagement and acknowledge whether such payments are impacted by the disclosed relationship.

Term and Termination

This disclosure and any obligations arising hereunder commence and terminate as set forth below unless earlier terminated in accordance with the termination provisions.

Effective Date:    Termination Date:

Confidentiality

Each party acknowledges that information regarding the disclosed relationship may be Confidential Information. "Confidential Information" means non-public information disclosed by one party to the other that is designated confidential or that reasonably should be understood to be confidential. Each receiving party shall:

• Use Confidential Information only for the purposes of performing obligations under the scope of work;
• Restrict disclosure to employees, contractors or agents with a need to know and who are bound by confidentiality obligations at least as protective as those herein;
• Take commercially reasonable measures to protect Confidential Information from unauthorized disclosure.

Mitigation and Remedies

Where a disclosed relationship creates or may create the appearance of bias or an actual conflict of interest, the parties agree to take reasonable mitigation steps including, but not limited to: disclosure to affected third parties, recusal from decision-making, independent review, or termination of the engagement. Remedies for breach may include injunctive relief, recovery of damages and termination of the engagement.

Governing Law

This Relationship Disclosure Form and any dispute arising out of or related to it shall be governed by and construed in accordance with the laws of the state specified below, without regard to conflict-of-law rules.

Entire Agreement

This form, together with any attachments and any separate written agreement expressly incorporated by reference, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written representations, understandings, or agreements. No amendment will be effective unless in writing and signed by both parties.

Certifications and Acknowledgements

Each party certifies that the disclosures made in this form are true, complete and made in good faith. Each party agrees to promptly supplement this disclosure if materially new information arises. False statements or omissions may constitute a breach and give rise to remedies under law or equity.

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