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DENIRO MARKETING, LLC RECORDS KEEPING COMPLIANCE FORM PURSUANT TO 18 U.S.C. § 2257 & 28 CFR §75.1 et seq.
MODEL IDENTIFYING INFORMATION AND AFFIDAVIT: Model understands that all the informationgiven in this Agreement is being provided to comply with United States federal law and any false statement will subject Model to both a civil action by Producer as well as criminal prosecution underUnited States federal and California state law. The information on this form may be shared with third parties including secondary producers, webmasters or distributors of the depictions created, to theextent necessary to comply with California state or United States federal law. _________
(Model’s Initials)

Please print legibly. a. Legal Name: __________________________________________________(Full Current Legal Name: First, Middle, Last)

b. Date of Birth: ____________
(Month, Day and Year)

Age: _____

c. The aforementioned information was acquired by the mandatory examination ofthe following Government-issued Picture ID card, such as a valid Driver’s License or a Passport: (The ID card should be described, including the ID number. A clear, goodquality photocopy of the ID mustbe attached to this Form and the photocopy must be signed in ink by Model): Government-Issued Picture Identification: Describe:____________________________ ID # _______________________________ Note:If ID does not contain a recent and recognizable picture of the Model, only a Drivers’ License, State ID Card or Military ID will be acceptable for U.S. Models; and only a passport will be acceptablefor foreign Models, in such circumstances. d. All other names ever used (include all stage names, Web handles, maiden names, aliases, professional names and nicknames): (1) ____________________________(a) _______________________________
(Stage Name for this Production) (All other names)

(2) ____________________________ (b) ______________________________
(Maiden Name if applicable) (All...
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