LAFetFilmFest: 2257 FORM

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

Age: _______________

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,  good­quality

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  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)
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 (using full legal name)

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 ORIGINALS OF EACH OF THE IDENTIFICATION DOCUMENTS OF

WHICH COPIES ARE ATTACHED HERETO AND SIGNED BY THE MODEL.

_____________________________  Today’s Date:  _________________

Signature of Primary Witness

_____________________________

Print Name of Witness

Copy of Depiction  Attached:  Hardcopy/Digital  Internet Location/URL:___________________________

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