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 a civil action by Producer as well as criminal prosecution under federal and state law.      _______

                                                                                                            (Model’s Initials)

 

a.          Legal Name: ____________________________       b.         Date of Birth: ____________            Age: _____

            (Full Current Legal Name First, Middle, Last)                      (Month, Day, Year)

 

c.          Primary identification document 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 other names previously 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)

 

e.          Phone # ( ) __________________ (optional)

 

SWORN STATEMENT: “UNDER 28 U.S.C. § 1746 AND THE PENALTIES 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)

 

 

SWORN STATEMENT: “UNDER 28 U.S.C. § 1746 AND THE PENALTIES 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 ORIGINALS OF EACH OF THE IDENTIFICATION DOCUMENTS OF WHICH COPIES ARE ATTACHED HERETO AND SIGNED BY THE MODEL.”

 

Signature:          _______________________________                    Today’s Date: ___________

(Signature of Primary Witness)

 

_______________________________

(Print Name of Primary Witness)