CERTIFICATE OF RETURN OR DESTRUCTION OF CONFIDENTIAL INFORMATION
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Effective Date: ________________________________________________________
Place: _________________________________________________________________

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1. Parties
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This document is made on ____________________ (____________________) by:

Receiving Party
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________

Addressed to:

Disclosing Party
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________

2. SUBJECT-MATTER SCHEDULE & SPECIFICATIONS
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Confidentiality Agreement (title and date):
    ____________________________________________________________________
Information and Materials Covered:
    ____________________________________________________________________
Returned, Destroyed or Deleted, and How:
    ____________________________________________________________________
Date Completed: ________________________________________________________
Copies Kept and Why, if Any: ___________________________________________

3. EXECUTION & SIGNATURES
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Receiving Party

Signature: _____________________________________________________________

Full Legal Name: _______________________________________________________
Date: __________________________________________________________________