Witness Signature Form

WITNESS SIGNATURE FORM

This Witness Signature Form is made between Signer Name: of Address: and Witness Name: of Address: executed on .

RECITALS

WHEREAS, Signer has executed or will execute the document titled: dated (the "Document");

WHEREAS, Witness has agreed to observe and attest to the signature of Signer on the Document and to provide a written attestation of such observation in accordance with the statements and certifications set forth below;

WHEREAS, the parties desire to reduce their understandings to writing and to set forth the attestations and acknowledgements of Witness as to identity, capacity and the circumstances of signing.

NOW, THEREFORE

In consideration of the mutual promises contained herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. WITNESS ATTESTATION

1.1 Witness affirms and certifies that Witness personally observed Signer sign the Document on the date set forth above and that the signature on the Document is the genuine signature of Signer. Witness further attests that, to the best of Witness's knowledge and belief, Signer was of sound mind and executed the Document voluntarily and without undue influence.

1.2 Witness confirms the following regarding the identity and appearance of Signer at the time of signing (check applicable boxes and provide details):

Signer was personally known to Witness.    Signer was identified to Witness by documentary identification. If identified, describe ID type and number:

2. STATEMENT OF CAPACITY

Witness states that at the time of signing Witness observed that Signer appeared to be of legal age and to possess the mental capacity to understand the nature and consequences of the Document. Witness makes no legal determination as to capacity beyond this observation, and nothing in this Form shall be construed as a substitution for a medical or legal determination of competency.

3. REPRESENTATIONS AND WARRANTIES

3.1 Signer represents and warrants that Signer executed the Document knowingly, voluntarily, and for the purposes stated therein, and that no person has coerced or unduly influenced Signer to execute the Document.

3.2 Witness represents that the information provided in this Witness Signature Form is true and correct to the best of Witness's knowledge and belief, and that Witness understands that false statements may give rise to civil liability.

4. LIMITATION OF LIABILITY AND INDEMNIFICATION

4.1 Except for willful misconduct or fraud, Witness shall not be liable for any inadvertent error or omission in this Form. Signer agrees to indemnify and hold harmless Witness from and against any claims, damages, losses or liabilities (including reasonable attorneys' fees) arising from Signer's breach of representation or from false statements made by Signer in connection with the Document.

5. NOTICES

Notices given under this Form shall be in writing and delivered by hand, nationally recognized overnight courier, or mailed by certified mail to the addresses set forth above and shall be effective upon receipt.

6. GOVERNING LAW

This Witness Signature Form shall be governed by and construed in accordance with the laws of the state or jurisdiction in which the Document was signed, without regard to conflict of laws principles.

7. ENTIRE AGREEMENT; SEVERABILITY

This Form constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written. If any provision of this Form is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

8. AMENDMENT; WAIVER; COUNTERPARTS

No amendment to or waiver of any provision of this Form shall be effective unless made in writing and signed by both parties. This Form 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. Electronic or facsimile signatures shall be treated as original signatures.

ADDITIONAL INFORMATION

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