State Notification Form

State Notification Form

Recitals

WHEREAS, the Notifying Party identified below is organized to conduct business under the laws of the State of and maintains records under registered business number ;

WHEREAS, applicable state statutes and administrative rules require notification to the designated State Liaison or agency when certain material changes or events occur; and

WHEREAS, the Notifying Party submits this State Notification Form to provide formal written notice of the event or change described herein and to document any agreed administrative response by the Recipient described below.

Notifying Party Information

Recipient / State Liaison

Notification Details

Notification Type (check all that apply):

Scope of Work / Required Actions

The parties acknowledge and agree that the Recipient may require the Notifying Party to take administrative or corrective actions in response to the notified event. The Notifying Party therefore agrees to perform the actions described below, to the extent required by the Recipient or applicable law:

Payment Terms (Administrative Fees)

If an administrative fee is required to process this notification, the Notifying Party shall pay the fee in accordance with the schedule below.

Term and Termination

This notification and any related agreed actions commence on and remain in effect until , unless earlier terminated as provided below.

Either party may terminate any mutual administrative arrangement under this form upon written notice delivered days prior to termination. Termination does not relieve the Notifying Party of obligations accruing prior to the effective date of termination.

Confidentiality

Except where disclosure is required by law or regulation, the Recipient agrees to maintain as confidential any non-public business information provided with this notification. The Recipient's obligation of confidentiality shall not apply to information that (a) is in the public domain through no fault of the Recipient, (b) was rightfully known to the Recipient prior to disclosure, or (c) is obtained independently from a third party having a lawful right to disclose. The Recipient shall use at least reasonable care to protect confidential information from unauthorized disclosure.

Certification

The undersigned certifies under penalty of perjury under the laws of the governing jurisdiction that the information contained in this State Notification Form is true, correct, and complete to the best of their knowledge and belief, and that they are authorized to submit this notification on behalf of the Notifying Party.

Governing Law

This form and any related agreement shall be governed by and construed in accordance with the laws of the State of , without regard to its conflict of laws principles.

Entire Agreement

This State Notification Form, together with any attachments listed herein, constitutes the entire understanding of the parties with respect to the subject matter and supersedes all prior written or oral agreements, representations, and understandings relating to the notification or the actions described herein.

Acknowledgment of Receipt (For Recipient Use)

Date Received:    Received By:

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