Service Agreement

Services Agreement

This Services Agreement (“Agreement”) is made this _____(the “Effective Date”) between__________ (“Customer”), with offices located at ________ and VTC Tax Credits, LLC. (“Service Provider”) with offices located at 12300 Ford Rd., Suite 450, Dallas, TX 75234.The Customer and Service Provider are sometimes collectively referred to herein as the “Parties” and individually as a “Party”. Attached as Exhibit A is an addendum, “Registration Form”, that corresponds to this paragraph identifying the “Customer”.

Customer wishes to be provided with the services (collectively the “Services” as defined below) by Service Provider and the Service Provider agrees to provide the Services to the Customer in accordance with the terms and conditions of this Agreement.

NOW, THEREFORE, in consideration of the mutual covenants and promises contained herein, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, and intending to be legally bound, the Parties agree as follows:

1. Services

1.01. The Customer hereby retains the Service Provider to perform the following Services on behalf of the Customer:

Locating potential employable veterans to fill open positions and including them in the database;
Aiding Employers to identify and source both Veteran and Non-Veteran target groups of the Department of Labor’s Work Opportunity Tax Credit Program through the Veteran database;
Electronic processing of WOTC eligible employees with the state workforce agencies;
Electronic processing of IRS 8850 and any supporting documentation to the state workforce agency within 28-day statutory deadline;
Granting software to assist employers with logging and documenting when each qualified employee reaches the 120 hour and 400-hour work requirements;
Maintaining electronic record of all Employer client files and will supply the year end IRS 5884 accounting of earned tax credits for Employer client to file with the companies.
Assisting Employers to obtain tax credits for employing veteran employees that qualify for a tax benefit.

Service Provider will determine the method, details, and means of performing the Services.

1.02. The Parties acknowledge and agree that during the term of the Agreement the Services may be modified and/or expanded from time to time upon a written agreement executed by authorized representatives of the Parties expressly referencing this Agreement.

1.03. Customer acknowledges and agrees that Service Provider may, at its sole discretion, use subcontractors and consultants to perform some of the Services to be provided under this Agreement.

1.04. Service Provider may represent, perform services for, and contract with other additional clients, persons, or companies as Service Provider, in [his/her/its] sole discretion, sees fit, provided those services do not pose a conflict of interest with the services performed for the Customer.

2. Fees and Expenses

2.01. Fees. As full consideration for the provision of the Services, Customer shall pay Service Provider fees in the amount that follows:

Subscriptions are annual and automatically renew on the anniversary date unless client gives 10 days notice prior to the renewal. Exception given for trial coupons (see 2.06 Coupons below)

1 Star (Either $29.95 monthly/$299.95 Annually)

– Unlimited Candidate WOTC Surveys
– Use of the VTC Applicant Tracking Software
– Access to the VTC Veteran Database
– *Complete Electronic WOTC processing (*15% Contingency Fee of Tax Credits Earned Applies)
– 2, 30 Day Job Posts Annually

2 Star (Either $59.95 monthly/$599.95 Annually)

3 Star (Either $99.95 monthly/$999.95 Annually)

Custom ($0 monthly/Charged $1 per Survey completed)

– Unlimited Candidate WOTC Surveys ($1 each)
– Use of the VTC Applicant Tracking Software

(This subscription is not open to the general public. It will be for business partnerships only and can only be set up manually. *Contingency fees may apply)

*Work Opportunity Tax Credit Contingency Fee –

A 15% contingency fee of the tax credit earned will be charged to your payment of record once an employee you submitted through the VTC software has been deemed certified by the applicable state government agency and met the statutory work requirements. Tax credits are earned per the following table:

Veterans
		Minimum Work Requirement
		120 Hours	400 Hours	120 Hours	400 Hours
Target Group	Wages Up To	For-Profit 25%	For-Profit 40%	Non-Profit 16.25%	Non-Profit 26%
Disabled veterans with a service-connected disability who have been unemployed for at least six months	24,000	6,000	9,600	3,900	6,240
Veterans who have been unemployed for at least six months	14,000	3,500	5,600	2,275	3,640
Disabled veterans with a service-connected disability	12,000	3,000	4,800	1,950	3,120
Veterans receiving SNAP benefits	6,000	1,500	2,400	975	1,560
Veterans who have been unemployed for at least four weeks	6,000	1,500	2,400	975	1,560

Non-Veterans
		Minimum Work Requirement
		120 Hours	400 Hours	Year 2
Target Group	Wage Cap	For-Profit 25%	For-Profit 40%	For-Profit 50%
Long-Term Family Assistance recipients who are members of a family that has received TANF benefits for at least 18 consecutive months (First Year)	10,000	N/A	4,000	N/A
Long-Term Family Assistance recipients who are members of a family that has received TANF benefits for at least 18 consecutive months (Second Year)	10,000	N/A	N/A	5,000
TANF recipients	6,000	1,500	2,400	N/A
Ex-felons	6,000	1,500	2,400	N/A
Designated community residents (Empowerment Zones expired 12/31/2016)	6,000	1,500	2,400	N/A
Vocational rehabilitation referrals	6,000	1,500	2,400	N/A
1	6,000	1,500	2,400	N/A
SNAP recipients	6,000	1,500	2,400	N/A
Supplemental Security Income recipients	6,000	1,500	2,400	N/A
Long-Term Unemployment Recipients	6,000	1,500	2,400	N/A
Summer Youth program participants who are 16 to 17 years old, work between May 1 and September 15 and live in an empowerment zone (Empowerment Zones expired 12/31/2016)	3,000	750	1,200	N/A

If an employee’s employment with your company is terminated prior to the minimum work requirement of 120 hours, no credit is earned. If an employee’s employment with your company is terminated after work requirements are met but prior to the maximum wage being paid, a proration of the tax credit will be paid based on the wages paid.

Example: An Employee that was certified as part of the Veteran Target Group as unemployed for 6 months prior to his hire with your company would qualify your company for a Tax Credit of 40% of the first $14000 of wages ($5600) once he/she worked for you for a minimum of 400 hours and has been paid $14000 of wages. In this scenario, the contingency fee charged to your company would be 15% of the $5600 credit.

Fees are subject to change at any time. VTC will provide a minimum of 30 days written notice prior to any change in fees.

2.02. Expenses. As full consideration for the provision of the Services, Customer shall pay Service Provider all expenses unless otherwise included in the price.

2.03. Final Determination. Final determination of eligibility for Tax Credits will be made by the particular State Agency in which your business and/or employee is located (W-2). Government agencies in each particular state (i.e. Texas Workforce Commission) determine eligibility for the applicable tax credits base upon the Federal Department of Labor Work Opportunity Tax Credit Program certification guidelines.

2.04. Billing and Payment. Service Provider shall prepare and submit an invoice to the Customer via [mail, email or facsimile] covering the total amount owed for Fees and Expenses for the project as agreed upon in this Agreement.

2.05. Compliance with Laws; Permits and Licenses. Customer agrees, at its own expense, to operate in full compliance with all governmental laws, regulations and requirements applicable to the duties conducted hereunder. It shall be the responsibility of the Customer to pay for any necessary licenses, permits, insurance and approvals as may be necessary for the performance of the Services under this Agreement, unless otherwise specified in writing and agreed to by the Service Provider.

2.06. Coupons. VTC may issue coupon codes that provide a discount and 30 day trial. If a customer uses a trial coupon code, customer may cancel the subscription prior to the end of the 30 day trial period with written notice to customerservice@veterantaxcredits.com. If notice is not given prior to the end of the 30 day trial, subscriptions will renew annually as per the service agreement.

3. Warranty. The Services to be performed hereunder include but are not limited to the following:

Locating potential employable veterans to fill open positions and including them in the database;
Aiding Employers to identify and source both Veteran and Non-Veteran target groups of the Department of Labor’s Work Opportunity Tax Credit Program through the Veteran database;
Electronic processing of WOTC eligible employees with the state workforce agencies;
Electronic processing of IRS 8850 and any supporting documentation to the state workforce agency within 28-day statutory deadline;
Granting software to assist employers with logging and documenting when each qualified employee reaches the 120 hour and 400-hour work requirements;
Maintaining electronic record of all Employer client files and will supply the year end IRS 5884 accounting of earned tax credits for Employer client to file with the companies.
Assisting Employers to obtain tax credits for employing veteran employees that qualify for a tax benefit.

Service Provider does not warrant in any form the results or achievements of the Services provided or the resulting work product and deliverables. Service Provider warrants that that the Services will be performed by qualified personnel in a professional and workmanlike manner in accordance with the generally accepted industry standards and practices. Service Provider shall comply with all statutes, ordinances, regulations and laws of all international, federal, state, county, municipal or local governments applicable to performing the Services hereunder.

LIMITATION OF WARRANTY. THE WARRANTY SET FORTH IN THIS SECTION 3. IS EXCLUSIVE AND IS IN LIEU OF ALL OTHER WARRANTIES, EXPRESS, IMPLIED, STATUTORY OR OTHERWISE WITH RESPECT TO THE SERVICES, WORK PRODUCT OR DELIVERABLES PROVIDED UNDER THIS AGREEMENT, OR AS TO THE RESULTS WHICH MAY BE OBTAINED THEREFROM. SERVICE PROVIDER DISCLAIMS ALL IMPLIED WARRANTIES INCLUDING, BUT NOT LIMITED TO, THE WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, OR AGAINST INFRINGEMENT. SERVICE PROVIDER SHALL NOT BE LIABLE FOR ANY SERVICES STATE AGENCY, GOVERNMENT AGENCY, OR WORK PRODUCT OR DELIVERABLES PROVIDED BY THIRD PARTY VENDORS IDENTIFIED OR REFERRED TO THE CUSTOMER BY THE SERVICE PROVIDER DURING THE TERM OF THIS AGREEMENT, PURSUANT TO ANY SOW OR OTHERWISE. CUSTOMER’S EXCLUSIVE REMEDY FOR BREACH OF THIS WARRANTY IS REPERFORMANCE OF THE SERVICES, OR IF REPERFORMANCE IS NOT POSSIBLE OR CONFORMING, REFUND OF AMOUNTS PAID UNDER THIS AGREEMENT FOR SUCH NON-CONFORMING SERVICES.

4. Ownership of Work Product.

The copyright in all deliverables created hereunder for Customer shall belong to the Service Provider. All intellectual property rights in all pre-existing works and derivative works of such pre-existing works and other deliverables and developments made, conceived, created, discovered, invented or reduced to practice in the performance of the Services hereunder are and shall remain the sole and absolute property of Service Provider, subject to a worldwide, non-exclusive license to Customer for its internal use as intended under this Agreement, and the Service Provider retains all moral rights therein. This Agreement does not grant Customer any license to any of the Service Provider’s products, which products must be separately licensed.

5. Confidential Information

5.01. Confidential Information. The Parties acknowledge that by reason of their relationship to the other hereunder, each may disclose or provide access (the “Disclosing Party”) to the other Party (the “Receiving Party”) certain Confidential Information. “Confidential Information” shall mean (i) information concerning a Party’s products, business and operations including, but not limited to, information relating to business plans, financial records, customers, suppliers, vendors, products, product samples, costs, sources, strategies, inventions, procedures, sales aids or literature, technical advice or knowledge, contractual agreements, pricing, price lists, product white paper, product specifications, trade secrets, procedures, distribution methods, inventories, marketing strategies and interests, algorithms, data, designs, drawings, work sheets, blueprints, concepts, samples, inventions, manufacturing processes, computer programs and systems and know-how or other intellectual property, of a Party and its affiliates that may be at any time furnished, communicated or delivered by the Disclosing Party to the Receiving Party, whether in oral, tangible, electronic or other form; (ii) the terms of any agreement, including this Agreement, and the discussions, negotiations and proposals related to any agreement; (iii) information acquired during any tours of or while present at a Party’s facilities; and (iv) all other non-public information provided by the Disclosing Party hereunder. In no event shall Service Provider’s use or disclosure of information regarding or relating to the development, improvement or use of any of Service Provider’s products be subject to any limitation or restriction. All Confidential Information shall remain the property of the Disclosing Party.

5.02. Use of Confidential Information; Standard of Care. The Receiving Party shall maintain the Confidential Information in strict confidence and disclose the Confidential Information only to its employees, subcontractors, consultants and representatives who have a need to know such Confidential Information to fulfill the business affairs and transactions between the Parties contemplated by this Agreement [and who are under confidentiality obligations no less restrictive as this Agreement]. The Receiving Party shall always remain responsible for breaches of this Agreement arising from the acts of its employees, subcontractors, consultants and representatives. Receiving Party shall use the same degree of care as it uses with respect to its own similar information, but no less than a reasonable degree of care, to protect the Confidential Information from any unauthorized use, disclosure, dissemination, or publication. Receiving Party shall only use the Confidential Information in furtherance of its performance of its obligations under this Agreement, and agrees not to use the Disclosing Party’s Confidential Information for any other purpose or for the benefit of any third party, without the prior written approval of the Disclosing Party. The Receiving Party shall not decompile, disassemble, or reverse engineer all or any part of the Confidential Information.

5.03. Exceptions. Confidential Information does not include information that: (a) was lawfully in Receiving Party’s possession before receipt from Disclosing Party; (b) at or after the time of disclosure, becomes generally available to the public other than through any act or omission of the Receiving Party; (c) is developed by Receiving Party independently of any Confidential Information it receives from Disclosing Party; (d) Receiving Party receives from a third party free to make such disclosure without, to the best of Receiving Party’s knowledge, breach of any legal or contractual obligation, or (e) is disclosed by Receiving Party with Disclosing Party’s prior written approval.

5.04. Required Disclosures. If the Receiving Party is confronted with legal action to disclose Confidential Information received under this Agreement, the Receiving Party shall, unless prohibited by applicable law, provide prompt written notice to the Disclosing Party to allow the Disclosing Party an opportunity to seek a protective order or other relief it deems appropriate, and Receiving Party shall reasonably assist disclosing Party in such efforts. If disclosure is nonetheless required, the Receiving Party shall limit its disclosure to only that portion of the Confidential Information which it is advised by its legal counsel must be disclosed.

5.05. Unauthorized Use or Disclosure of Confidential Information; Equitable Relief. In the event the Receiving Party discovers that any Confidential Information has been used, disseminated or accessed in violation of this Agreement, it will immediately notify the Disclosing Party, take all commercially reasonable actions available to minimize the impact of the use, dissemination or publication, and take all necessary steps to prevent any further breach of this Agreement. The Parties agree and acknowledge that any breach or threatened breach regarding the treatment of the Confidential Information may result in irreparable harm to the Disclosing Party for which there may be no adequate remedy at law. In such event the Disclosing Party shall be entitled to seek an injunction, without the necessity of posting a bond, to prevent any further breach of this Agreement, in addition to all other remedies available in law or at equity.

5.06. Return of Confidential Information; Survival. Receiving Party shall promptly return or, at Disclosing Party’s option, certify destruction of all copies of Confidential Information at any time upon request or within [number, e.g., 30] days following the expiration or earlier termination of this Agreement. Notwithstanding any expiration or termination of this Agreement, Receiving Party’s obligations to protect the Confidential Information pursuant to this Section will survive for [number, e.g., two] years after the expiration or earlier termination of this Agreement.

6. Indemnification.

Each party (the “Indemnifying Party”) agrees to indemnify, defend and hold the other party and its affiliates and their respective officers, directors, employees and agents harmless from and against all third-party claims, losses, liabilities, damages, expenses and costs, including attorney’s fees and court costs, arising out of the Indemnifying Party’s (i) [gross] negligence or willful misconduct or (ii) its material breach of any of the terms of this Agreement. The Indemnifying Party’s liability under this Section shall be reduced proportionally to the extent that any act or omission of the other Party, or its employees or agents, contributed to such liability. The party seeking indemnification shall provide the Indemnifying Party with prompt written notice of any claim and give complete control of the defense and settlement of the Indemnifying Party, and shall cooperate with the Indemnifying Party, its insurance company and its legal counsel in its defense of such claim(s). This indemnity shall not cover any claim in which there is a failure to give the Indemnifying Party prompt notice to the extent such lack of notice prejudices the defense of the claim.

SECTION 6. STATES THE ENTIRE OBLIGATION AND THE EXCLUSIVE REMEDIES WITH RESPECT TO THE PARTIES’ INDEMNIFICATION OBLIGATIONS PURSUANT TO THIS AGREEMENT.

7. LIMITATION OF LIABILITY; ACTIONS

EXCEPT FOR THE PARTIES CONFIDENTIALITY OBLIGATIONS UNDER SECTION 5. OF THIS AGREEMENT AND INDEMNIFICATION OBLIGATIONS UNDER SECTION 6. OF THIS AGREEMENT, IN NO EVENT SHALL EITHER PARTY BE LIABLE UNDER THIS AGREEMENT TO THE OTHER PARTY FOR ANY INCIDENTAL, CONSEQUENTIAL, INDIRECT, STATUTORY, SPECIAL, EXEMPLARY OR PUNITIVE DAMAGES, INCLUDING, BUT NOT LIMITED TO, LOST PROFITS, LOSS OF USE, LOSS OF TIME, INCONVENIENCE, LOST BUSINESS OPPORTUNITIES, DAMAGE TO GOOD WILL OR REPUTATION, AND COSTS OF COVER, REGARDLESS OF WHETHER SUCH LIABILITY IS BASED ON BREACH OF CONTRACT, TORT, STRICT LIABILITY OR OTHERWISE, AND EVEN IF ADVISED OF THE POSSIBILITY OF SUCH DAMAGES OR SUCH DAMAGES COULD HAVE BEEN REASONABLY FORESEEN. SUBJECT TO THE CUSTOMER’S OBLIGATION TO PAY THE FEES TO THE SERVICE PROVIDER, EACH PARTY’S ENTIRE AGGREGATE LIABILITY FOR ANY CLAIMS RELATING TO THE SERVICES OR THIS AGREEMENT SHALL NOT EXCEED THE FEES PAID OR PAYABLE BY THE CUSTOMER TO THE SERVICE PROVIDER UNDER THIS AGREEMENT IN THE MONTH PERIOD IMMEDIATELY PRECEDING THE EVENTS GIVING RISE TO SUCH LIABILITY. THIS SECTION SHALL SURVIVE THE TERMINATION OF THE AGREEMENT.

NO ACTION SHALL BE BROUGHT FOR ANY CLAIM RELATING TO OR ARISING OUT OF THIS AGREEMENT MORE THAN ONE (1) YEAR AFTER THE ACCRUAL OF SUCH CAUSE OF ACTION, EXCEPT FOR MONEY DUE ON AN OPEN ACCOUNT

9. Arbitration

Any and all unresolved issues, disputes, controversies, or causes of action, whether in the nature of a tort or contract, that arise from or relates to the services of VTC Tax Credits by and through this service agreement, such issues, disputes, and causes of actions shall be submitted exclusively to binding arbitration by and through the American Arbitration Association. Each Party will be responsible for their own reasonable attorney’s fees.

8. Cooperation of Customer.

Customer agrees to comply with all reasonable requests of Service Provider and shall provide Service Provider’s personnel with access to all documents and facilities as may be reasonably necessary for the performance of the Services under this Agreement.

9. Term.

This Agreement shall have an initial term of one year from the Effective Date (the date payment is received) unless earlier terminated by mutual agreement of the parties. Thereafter, the Agreement shall be automatically renewed for additional one-year terms (each a “Renewal Term”), unless not less than 10 days prior to the end of the Initial Term or any Renewal Term, either Party notifies the other of its intent not to renew the Agreement. The Initial Term and Renewal Terms, if any, are collectively referred to herein as the “Term”.

10. Relationship of the Parties.

The relationship of the Parties hereto is that of independent contractors. Nothing in this Agreement, and no course of dealing between the Parties, shall be construed to create or imply an employment or agency relationship or a partnership or joint venture relationship between the Parties or between one Party and the other Party’s employees or agents. Each of the Parties is an independent contractor and neither Party has the authority to bind or contract any obligation in the name of or on account of the other Party or to incur any liability or make any statements, representations, warranties or commitments on behalf of the other Party, or otherwise act on behalf of the other. Each Party shall be solely responsible for payment of the salaries of its employees and personnel (including withholding of income taxes and social security), workers’ compensation, and all other employment benefits.

11. Force Majeure.

Neither Party shall be liable hereunder for any failure or delay in the performance of its obligations under this Agreement, except for the payment of money, if such failure or delay is on account of causes beyond its reasonable control, including civil commotion, war, fires, floods, accident, earthquakes, inclement weather, telecommunications line failures, electrical outages, network failures, governmental regulations or controls, casualty, strikes or labor disputes, terrorism, acts of God, or other similar or different occurrences beyond the reasonable control of the Party so defaulting or delaying in the performance of this Agreement, for so long as such force majeure event is in effect. Each Party shall use reasonable efforts to notify the other Party of the occurrence of such an event within [number, e.g., five] business days of its occurrence.

12. Governing Law and Venue.

This Agreement will be governed by and interpreted in accordance with the laws of the State of Texas without giving effect to the principles of conflicts of law of such state. The UN Convention on Contracts for the International Sale of Goods shall not apply to this Agreement. The Parties hereby agree that any action arising out of this Agreement will be brought solely in any state or federal court located Dallas County pursuant to arbitration agreement. Both Parties hereby submit to the exclusive jurisdiction and venue of any such court.

13. Attorney’s Fees.

If either Party incurs any legal fees associated with the enforcement of this Agreement or any rights under this Agreement, each party will be responsible for their own attorney’s fees.

14. Collection Expenses.

If Service Provider incurs any costs, expenses, or fees, including reasonable attorney’s fees and professional collection services fees, in connection with the collection or payment of any amounts due it under this Agreement, Customer agrees to reimburse Service Provider for all such costs, expenses and fees.

15. Assignment.

The Service Provider may subcontract its obligations and rights to a third-party.

16. Severability.

If any provision or portion of this Agreement shall be rendered by applicable law or held by a court of competent jurisdiction to be illegal, invalid, or unenforceable, the remaining provisions or portions shall remain in full force and effect.

17. Headings; Construction.

The headings/captions appearing in this Agreement have been inserted for the purposes of convenience and ready reference, and do not purport to and shall not be deemed to define, limit or extend the scope or intent of the provisions to which they appertain. This Agreement is the result of negotiations between the Parties and their counsel. Accordingly, this Agreement shall not be construed more strongly against either Party regardless of which Party is more responsible for its preparation, and any ambiguity that might exist herein shall not be construed against the drafting Party.

18. Survival.

Each term and provision of this Agreement that should by its sense and context survive any termination or expiration of this Agreement, shall so survive regardless of the cause and even if resulting from the material breach of either Party to this Agreement.

19. Rights Cumulative.

The rights and remedies of the Parties herein provided shall be cumulative and not exclusive of any rights or remedies provided by law or equity.

20. Counterparts.

This Agreement may be executed in one or more counterparts, each of which will be deemed to be an original, but all of which together will constitute one and the same instrument, without necessity of production of the others. An executed signature page delivered via facsimile transmission or electronic signature shall be deemed as effective as an original executed signature page.

21. Authorized Signatories.

It is agreed and warranted by the Parties that the individuals singing this Agreement on behalf of the respective Parties are authorized to execute such an agreement. No further proof of authorization shall be required.

22. Notices.

All notices or other communications required under this Agreement shall be in writing and shall be deemed effective when received and made in writing by either (i) hand delivery, (ii) registered mail, (iii) certified mail, return receipt requested, (iv) email or electronic facsimile, or (v) overnight mail, addressed to the Party to be notified at the following address or to such other address as such Party shall specify by like notice hereunder:

23. Waiver.

No waiver of any term or right in this Agreement shall be effective unless in writing, signed by an authorized representative of the waiving Party. The failure of either Party to enforce any provision of this Agreement shall not be construed as a waiver or modification of such provision, or impairment of its right to enforce such provision or any other provision of this Agreement thereafter.

24. Entire Agreement;

Modification. This Agreement, [and any exhibits attached hereto,] is the entire Agreement between the Parties with respect to the subject matter hereof and supersedes any prior agreement or communications between the Parties, whether written, oral, electronic or otherwise. No change, modification, amendment, or addition of or to this Agreement or any part thereof shall be valid unless in writing and signed by authorized representatives of the Parties. Each Party hereto has received independent legal advice regarding this Agreement and their respective rights and obligations set forth herein. The Parties acknowledge and agree that they are not relying upon any representations or statements made by the other Party or the other Party’s employees, agents, representatives or attorneys regarding this Agreement, except to the extent such representations are expressly set forth in this Agreement.
In witness whereof, the Parties hereto have executed this Services Agreement on the date set forth below.

CUSTOMER
By: ___________________
Name: [insert signer’s name]
Title: [insert signer’s title]
Date: [insert date]

SERVICE PROVIDER
By: ___________________
Name: [insert signer’s name]
Title: [insert signer’s title]
Date: [insert date]