UBO Declaration Statement

UBO DECLARATION STATEMENT

This UBO Declaration Statement (the Statement) is made as of the date set forth below by and between Declarant Name: , a legal entity organized as Entity Type: Corporation Partnership Trust Other , Registration Number: , Registered Address: ; and Recipient Name: , Recipient Address: .

RECITALS

WHEREAS, Recipient requires information regarding the natural persons who ultimately own or exercise control over Declarant in order to satisfy applicable anti-money laundering, counter-terrorist financing, and sanctions compliance requirements; and

WHEREAS, Declarant has or will provide the information set forth in this Statement to enable Recipient to assess ownership and control and to verify the identity of Ultimate Beneficial Owners (UBOs); and

WHEREAS, the parties intend that the representations, warranties and covenants contained in this Statement shall govern the accuracy and use of the information provided.

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the sufficiency of which is acknowledged, the parties agree as follows:

1. DEFINITIONS

For the purposes of this Statement, "Ultimate Beneficial Owner" or "UBO" means any natural person who, directly or indirectly, (a) owns 25% or more of the ownership interest in Declarant; or (b) otherwise exercises control over Declarant through ownership, voting rights, contractual arrangements, or other means. "Control" includes the ability to direct management, policy, or significant decisions.

2. DECLARATION OF ULTIMATE BENEFICIAL OWNERS

Declarant hereby declares, represents and warrants that the following natural persons are the UBOs of Declarant as of the Date of Declaration below. For each UBO, Declarant provides the information reasonably requested by Recipient to verify identity and ownership/control.

Declarant affirms that no natural person meets the definition of Ultimate Beneficial Owner for Declarant under the definitions contained herein and applicable law.

3. REPRESENTATIONS AND WARRANTIES

Declarant represents and warrants that, to the best of its knowledge after reasonable inquiry, the information provided in this Statement is true, complete and correct in all material respects. Declarant shall promptly notify Recipient in writing of any change to the information provided, and in any event within thirty (30) days of becoming aware of such change.

4. CONSENT TO VERIFICATION AND USE

Declarant authorizes Recipient to verify any information provided, to obtain additional information or documentation reasonably necessary to confirm identities, and to disclose such information to regulatory authorities, auditors, third-party service providers, and other parties as required or permitted by law or regulation. Recipient will use such information for compliance, recordkeeping, and reporting obligations.

5. FALSE STATEMENTS; INDEMNITY

Declarant acknowledges that knowingly providing false information in this Statement may constitute a criminal offense or regulatory violation under applicable law. Declarant agrees to indemnify and hold harmless Recipient from and against all losses, liabilities, fines, penalties, costs and expenses (including reasonable attorneys' fees) arising from any material misrepresentation or omission in this Statement, or from Declarant's failure to provide timely updates.

6. NOTICES

All notices, requests, demands and other communications required or permitted under this Statement shall be in writing and delivered to the addresses set forth below or to such other addresses as either party may designate in writing.

7. GOVERNING LAW

This Statement shall be governed by and construed in accordance with the laws of the jurisdiction set forth below, without regard to conflict of law principles. Governing Law Jurisdiction:

8. ENTIRE AGREEMENT; SEVERABILITY; AMENDMENT

This Statement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous oral or written agreements. If any provision of this Statement is held invalid or unenforceable, the remaining provisions shall continue in full force and effect. This Statement may be amended only by a written instrument signed by both parties.

9. COUNTERPARTS

This Statement 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. Signatures transmitted electronically or by facsimile shall be binding.

CERTIFICATION

By signing below, Declarant certifies under penalty of perjury that the information provided in this Statement is true, complete and accurate to the best of Declarant's knowledge and that Declarant is authorized to make this certification on behalf of the Declarant entity. Declarant further acknowledges its obligation to update Recipient promptly upon any material change.

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