Housekeeper

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STATE OF ARIZONA )

) ss.

COUNTY OF MARICOPA )

ARIZONA RULE OF CIVIL PROCEDURE

80(i) DECLARATION REGARDING

INSURANCE

I, upon my oath, depose and say the following: 1. On, 2022, I was the owner and operator of a that was involved in an crash in, Arizona (“the crash”); 2. The only automobile insurance policy on the vehicle was issued by . 3. On the date of the crash, neither I, nor my spouse were insured under any commercial general liability policy, umbrella (personal or otherwise) or any other policy that provided or could potentially provide coverage to or for me or, my spouse or child, for any claims relating to operation of a motor vehicle;

4. I was not insured by any other insurance policies on the date of the crash; 5. I have no knowledge of any other insurance that would cover any of the damages resulting from the crash;

6. I have no knowledge of any other insurance that might even apply and/or potentially cover any of the damages resulting from the crash; 7. I do not own a home and I have no property or assets that could be sold to pay a judgment against me or I own my home, but the equity in the home is less than $20,000

(circle one);

8. I was not in the course and scope of my employment at the time of the crash; 9. I have less than $10,000 in savings and checking accounts; and 10. I understand that these representations are all material to any decision made not to sue me. In the event that any other insurance policy or coverage under my policy is discovered that could possibly provide coverage to me for this claim, it is my wish and intent that the statute of limitations applicable to any such claim be tolled until one year from the date of the discovery of any such insurance. I hereby instruct any insurance carriers insuring or defending me in any way, or attorneys representing me (and promise for myself in the event I am not represented by counsel) not to assert the statute of limitations as a defense to any such action brought after the discovery of additional insurance. Page 2 of 2

I swear, under penalty of perjury, that the foregoing is true and correct. I understand that the settlement of the crash claim is made on the condition that this declaration is executed in good faith and under penalty of perjury. I understand that if any of the above information is inaccurate and I nevertheless execute this affidavit, it will result in a breach of the settlement agreement in this matter.

Dated this day of, 2022.

The foregoing was signed before me this day of, 2022, by WITNESS

7696271v1/29568-0001

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