CLIENT ATTESTATION

AS REQUIRED BY THE
International Marriage Broker Regulation Act of 2005

Client Name: (Print name)_________________________________________________________________

Last First Middle Initial Date of Birth

Please answer to the following questions by placing a checkmark next to “Yes” or “No” or fill in the blank as instructed and
provide supporting documentation as required. Complete this form, hit submit, and upload any supporting documentation.

1. List all the States and Countries you have resided in since you were 18 years of age:

State and/or Country #1: _____________ State and/or Country #4: _____________

State and/or Country #2: _____________ State and/or Country #5: _____________

State and/or Country #3: _____________ State and/or Country #6: _____________

2. How many children do you have under the age of 18? _____ (Enter number of children or “0” if none.)

If you have children under the age of 18, list their ages:

Age of child #1: _____________ Age of child #4: _____________

Age of child #2: _____________ Age of child #5: _____________

Age of child #3: _____________ Age of child #6: _____________

3. Marital History:

Are you currently married? _____ Yes _____ No

Have you previously been married? _____ Yes _____ No

If you have been married, how many times? _____ (Enter number of times or “0” if none.)

If previous marriages were terminated, list How (i.e. death of spouse, annulment, divorce, etc.)
and Date of termination below:

How __________________________________ Date _________________________

How __________________________________ Date _________________________

How __________________________________ Date _________________________

Have you previously sponsored an alien to whom you were engaged or married? _____ Yes _____ No

4. Have you ever been named in any court order that restricted your physical or other contact with, behavior towards, or
communication with another person, including any temporary or permanent civil restraining order or protection order?

_____ Yes (If yes, upload a copy of the court order.) _____ No

Client Attestation (Page 1 of 2)

 5. Have you ever been arrested or convicted by any Federal, State, or local law enforcement agency for homicide, murder,
manslaughter, assault, battery, domestic violence, rape, sexual assault, abusive sexual contact, sexual exploitation, incest,
child abuse or neglect, torture, trafficking, peonage, holding hostage, involuntary servitude, slave trade, kidnapping,
abduction, unlawful criminal restraint, false imprisonment, or stalking?

_____ Yes (If yes, upload a copy of the arrest record and/or conviction.) _____ No

6. Have you ever been arrested or convicted by any Federal, State, or local law enforcement agency for solely, principally, or
incidentally engaging in prostitution; or for any direct or indirect attempt to procure prostitutes or persons for the purpose
of prostitution; or any receiving, in whole or in part, of the proceeds of prostitution?

_____ Yes (If yes, upload a copy of the arrest record and/or conviction.) _____ No

7. Have you ever been arrested or convicted by any Federal, State, or local law enforcement agency for offenses related to
controlled substances or alcohol?

_____ Yes (If yes, upload a copy of the arrest record and/or conviction.) _____ No

I, (Print name) _____________________________________, hereby declare, under penalty of the provisions of 18 U.S.C. 1001, that the information I
have provided on this “Client Attestation” is to the best of my knowledge truthful, accurate, and complete. Further, I hereby authorize the
International Marriage Broker (IMB) to whom I have submitted this attestation and any accompanying documentation (“background information”)
to provide my background information to Foreign Nationals for whom I request personal contact information. I understand and acknowledge that
release of my background information does not entitle me to the requested Foreign National’s personal contact information in and of itself, but that
the request for personal contact information must first be translated into the Foreign National’s primary language and then return authorization in
writing from the Foreign National permitting release of their personal contact information must be received. I further understand and acknowledge
that any act or attempt, either willful or inadvertent, on my part solely, or in concert with a Foreign National, or in concert with another IMB,
whether of domestic or foreign registry, to circumvent the information notification and release provisions of the International Marriage Broker
Regulation Act of 2005, is a violation of that Act and I hereby indemnify and hold harmless the International Marriage Broker to whom I’ve
submitted this attestation from any criminal or civil liability associated with such acts or attempts. I do certify and attest that I will not attempt any
direct contact with any Foreign National whose initial contact has been facilitated by the IMB to which this attestation is submitted without full
cooperation with and adherence to the information notification and release requirements of the International Marriage Broker Regulation Act of
2005.

______________________________________________________ ________________________
Signature of Client Date

Notice

The information supplied on this form will be used to check the National Sex Offender Public Registry or the State sex offender public registry for information
regarding the above Client.

Date of registry search: ____________________ ____ Records were found (See attached)

____ No records were found (Confirmation attached)

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