RECORDS KEEPING COMPLIANCE FORM PURSUANT TO 18 U.S.C. ¶2257

 

MODEL IDENTIFYING INFORMATION AND AFFIDAVIT:  Model understands that all the information given in this Agreement is being provided to comply with federal law and any false statement will subject Model to both civil action by Producer as well as criminal prosecution under federal and state law. _______________ (Model’s Initials)
 

  1. Legal Name: ________________________             b. Date of Birth: ___________________

                                                                                                                                                       (Month, Day and Year)

                       Age___________

c.          Primary identification documents must be government issued passport, driver’s license, motor vehicle department ID or military ID:  (Each should be described, including the ID number.  Clear, good-quality photocopies of each must be attached to this form and the photocopies must be signed in ink by Model)

(1) First form of identification:                                        (2) Second form of identification:

______________________________                           ________________________________

ID # __________________________                           ID #_____________________________
 

d.             All of the names ever used (include previous legal names, stage names, Web handles, maiden or married names, aliases, professional names and nicknames):

(1)___________________________                              (a) ______________________________

      (Stage Name for this Production)                                        (All other names)
 

(2)___________________________                            (b) ______________________________

      (Maiden Name, if applicable                                                    (All other names)
 

(3)___________________________                                (c) ______________________________

      (Previous legal name, if applicable)                                     (All other names)

 

SWORN STATEMENT:  “UNDER 28 U.S.C ¶1746 AND THE PENTALTIES OF PERJURY UNDER THE LAWS OF THE UNITED STATES, I SWEAR THAT THE FOREGOING IS TRUE AND CORRECT AND THAT EACH OF THE IDENTIFICATION DOCUMENTS WHICH I HAVE PROVIDED AND OF WHICH I HAVE SIGNED THE ATTACHED COPY WAS LAWFULLY OBTAINED BY ME AND HAS NOT BEEN FORGED OR ALTERED.”

 

Signature:________________________________________                       Today’s Date:_____________________

                  Model’s Signature (using full legal name)                                                                             (Month, Day and Year)        
                                                                                 

MODEL MUST ALSO SIGN ATTACHED COPIES!

UNDER 28 U.S.C. ¶1746 AND THE PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES, I SWEAR THAT I BELIEVE THE FOREGOING IS TRUE AND CORRECT, THAT I HAVE PERSONALLY EXAMINED THE MODEL’S PHOTO IDENTIFICATION AND DATE OF BIRTH, AND THAT I HAVE OBSERVED THE ORGINALS OF EACH OF THE IDENTIFICATION DOCUMENTS OF WHICH COPIES ARE ATTACHED HERETO AND SIGNED BY THE MODEL.

 

_____________________________________                              Today’s Date: _____________________

Signature of Primary Witness                                                                                                (Month, Day and Year)

 

 

_____________________________________

Print Name of Witness