SIMPLE SWORN STATEMENT

In the city of Asunción, Republic of Paraguay, on [Date: e.g. 05/02/2026], appears on one side [Party A name: e.g. Juan Pérez], holder of ID No. [Party A ID: e.g. 1,234,567], domiciled at [Party A address: e.g. Asunción], hereinafter "PARTY A"; and on the other side [Party B name: e.g. María González], holder of ID/Tax ID No. [Party B ID/Tax ID: e.g. 80012345-6], domiciled at [Party B address: e.g. San Lorenzo], hereinafter "PARTY B". The parties state that they have sufficient capacity to bind themselves and agree to execute this private instrument, subject to the following clauses:

FIRST: PURPOSE

PARTY A and PARTY B agree to to record the statement made by [Declarant: e.g. Juan Pérez] regarding [Declared fact]. This agreement shall be interpreted in good faith, according to its economic purpose and prudent Paraguayan legal practice.

SECOND: PRICE AND PAYMENT METHOD

As consideration, price, rent, contribution or economic acknowledgment, according to the nature of the act, the parties establish there is no price or consideration for this statement. Every payment must be documented by receipt, bank voucher or sufficient written record.

THIRD: TERM

The term or effectiveness shall be the statement is issued on [Date: e.g. 05/02/2026] for the indicated purposes. Any extension, suspension or amendment must be made in writing and physically or digitally signed by the parties.

FOURTH: OBLIGATIONS OF THE PARTIES

• The DECLARANT states that the information is true to the best of their knowledge.
• The document may be presented where applicable if accepted.
• The declarant assumes responsibility for falsehood or relevant omission.

FIFTH: REPRESENTATIONS AND WARRANTIES

The parties declare that the stated information is true, that they act without fraud, mistake, violence or intimidation, and that they know the legal and economic scope of the obligations assumed. Some institutions may require signature certification, own form or notarial declaration.

SIXTH: BREACH

Serious breach, unjustified default or lack of essential cooperation shall entitle the performing party to request performance, termination or compensation that may correspond, after notice by reliable means when the nature of the obligation permits it.

SEVENTH: ADDRESSES AND NOTICES

For all purposes of this agreement, the parties establish as special addresses those indicated in the appearance section, where written communications, emails and notices related to performance of the agreement shall be valid.

EIGHTH: JURISDICTION

For any dispute arising from this instrument, the parties shall seek an amicable solution. If disagreement persists, they submit to the competent ordinary courts of the Republic of Paraguay, without prejudice to mandatory rules applicable by subject matter or territory.

NINTH: ACCEPTANCE

Having read this document and as evidence of agreement, the parties sign two counterparts of the same tenor and for one single effect, at the place and date indicated above.

PARTY A signature: ___________________________

PARTY B signature: ___________________________