Terrorism Affidavit Form

Terrorism Affidavit Form

This Terrorism Affidavit Form is executed as of by Affiant Name: whose address is (hereinafter "Affiant"), and Recipient Name: whose address is (hereinafter "Recipient").

Recitals

WHEREAS, Recipient requires a sworn affidavit from Affiant as a condition to initiating, continuing, or concluding certain transactions, services, or contractual relationships in order to comply with applicable anti-terrorism financing laws and regulations; and

WHEREAS, Affiant acknowledges that Recipient will rely upon the representations, warranties, and certifications contained herein as a material inducement to provide services, enter into agreements, or process transactions; and

WHEREAS, Affiant is willing to make the representations and certifications set forth below under oath and subject to penalty of perjury.

Now, Therefore

NOW, THEREFORE, in consideration of the foregoing recitals and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, Affiant hereby certifies, warrants, and agrees as follows:

1. Definitions

For purposes of this Affidavit, the following terms have the meanings set forth below:

"Affiant" means the individual or entity identified above and any signatory executing this Affidavit on its behalf. "Recipient" means the entity identified above that requests and relies upon this Affidavit. "Prohibited Person" means an individual or entity that is the subject of sanctions, designated as a terrorist or terrorist organization, or otherwise barred under applicable anti-terrorism or sanctions laws. "Terrorist Financing" means providing, collecting, transmitting, or facilitating funds, goods, services, or other support to or for the benefit of a Prohibited Person or for terrorist activities.

2. Representations and Warranties of Affiant

Affiant represents and warrants to Recipient, which representations and warranties are true and correct as of the date hereof and shall be continuing representations and warranties, that:

(a) Affiant is not a Prohibited Person and is not included on any government, regulatory, or intergovernmental organization's list of designated terrorists, terrorist organizations, or sanctioned parties known to Affiant to be applicable to the transaction or relationship with Recipient.

(b) Affiant has not, directly or indirectly, provided funds, assets, goods, services, or other support to a Prohibited Person or for the purpose of furthering terrorist activities, nor has Affiant engaged in any conduct intended to evade or circumvent applicable anti-terrorism or sanctions obligations.

(c) All information provided by Affiant to Recipient in connection with the transaction or relationship described in this Affidavit, including identity, ownership, and source of funds information, is true, accurate, and complete to Affiant's knowledge.

3. Additional Covenants

Affiant covenants that Affiant shall promptly notify Recipient in writing within five (5) business days if Affiant becomes aware of any change in circumstances that would render any representation or warranty contained in this Affidavit inaccurate or incomplete. Notification shall be given in accordance with the Notices provision below.

4. Certification Under Penalty of Perjury

Affiant certifies under penalty of perjury under applicable law that the statements contained in this Affidavit are true and correct to the best of Affiant's knowledge, information, and belief. Affiant acknowledges that willful false statements made herein may subject Affiant to civil and criminal penalties under applicable statutes.

5. False Statements; Remedies

In the event of any breach of the representations, warranties, or covenants in this Affidavit, Recipient shall have the right to suspend performance, terminate any related agreements, refuse transactions, and pursue all remedies available at law or in equity, including recovery of damages and indemnification for losses, costs, and expenses (including reasonable attorneys' fees).

6. Indemnity

Affiant agrees to indemnify, defend, and hold harmless Recipient and its affiliates, officers, directors, agents, and employees from and against any and all claims, liabilities, losses, damages, fines, penalties, costs, and expenses (including reasonable attorneys' fees) arising out of or resulting from any breach of the representations, warranties, or covenants contained in this Affidavit or from any false statement made by Affiant in connection with this Affidavit.

7. Notices

Notices shall be in writing and shall be deemed to have been duly given when delivered personally, sent by nationally recognized overnight courier, or mailed by certified mail, return receipt requested, to the notice address provided above or to such other addresses as a party may specify in writing in accordance with this provision.

8. Governing Law; Venue

This Affidavit shall be governed by and construed in accordance with the laws of the jurisdiction specified below without regard to conflict of laws principles. The parties agree that exclusive venue for any legal action arising out of this Affidavit shall be in the courts of such jurisdiction.

9. Entire Agreement; Amendments; Severability; Waiver; Counterparts

This Affidavit constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior understandings, agreements, and communications concerning such subject matter. Any amendment to this Affidavit must be in writing and signed by both parties. If any provision of this Affidavit is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect. No waiver of any breach shall be effective unless in writing and signed by the party granting the waiver. This Affidavit may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument.

10. Additional Declarations

Affiant Representations Regarding Entity Type

Entity Type (check the box that applies):

Individual Corporation Trust Other

Acknowledgment

Affiant acknowledges that Recipient may disclose the contents of this Affidavit to governmental authorities or financial institutions as required by law or as necessary to fulfill compliance obligations. Affiant further acknowledges that Recipient may take such actions as it deems necessary, including suspending services or closing accounts, when information indicates potential terrorism financing or sanctions risk.

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