(September 24, 2019)
My Name
1. Are you aware of the Formal Complaint & Declaration? Yes / No
a. If you answered no, do you want to know about the Formal Complaint & Declaration to participate in
the investigation? Yes / No
b. If you answered yes to 1, are you willing to participate in the investigation? Yes / No (*Note: If
you answered, “Noto 1(a) or (b), please stop here and return the form to legal@myrenatus.com).
2. If you answered yes to 1(b), then answering the following questions will help the Company understand what
level of participation you are willing to have in the investigation:
a. Are you willing to provide a written statement? Yes / No (*Note: before answering this and
the remaining questions, please see “Warningsnear the signature line at the end of this form)
i. If so, please fill out the other side of this form in the Witness Statement, sign, and date.
b. Are you willing to participate in a recorded telephonic interview? Yes / No
c. Are you willing to participate in a telephonic interview, but do not want it recorded? Yes / No
d. Are you willing to provide documentation in support of your Witness Statement? Yes / No
i. If so, please provide documentation when you return this form.
e. Are you willing to list additional witnesses you believe would have information related to the
investigation. If so, please include them below.
f. Will you assist the Company in contacting the witnesses? Yes / No
Please check the box if the witness is aware you are listing them as a witness. By listing these witnesses, you understand
that the Company will be contacting them. You may attach additional sheets.
As soon as possible, please return this completed form to legal@myrenatus.com.
You are being provided this Witness Survey & Declaration form because you were listed as a potential witness in a
Formal Complaint & Declaration (“Complaint”) or Response & Declaration (“Response”) filed with Renatus, LLC (“the
Company”). The Formal Complaint and Declaration has triggered an investigation into an ICM(s) personal conduct or
business practices that may have harmed the complainant, others or the Company. Based upon the investigation, the
Company will decide whether the ICM(s) and/or his/her business’ status as an active Independent Contracted
Marketer (“ICM”) should be changed to probation or suspension, whether to terminate the ICM Agreement for
breach, and/or change the upline affiliate status regarding the complainant and/or others. The Company requests
you fill out the following survey and make a written statement, if you choose to do so. Thank you in advance for your
time and willingness to assist the Company in investigating this matter and making this important decision.
By signing below, I certify under criminal penalty of the State of Utah that the foregoing is true and correct.
Please include relevant, detailed, specific facts based upon personal knowledge (not hearsay or rumors) that is
related to the Complaint and/or response, including harm, a timeline, who, what, where, when, how and why. You
may attach additional sheets to provide complete information regarding your statement. The Company’s decision
will be based upon the results of the investigation, which may include the ICM(s): compliance history with the
Company, business practices, personal conduct, reputation, harm to complainant and/or others, and risk.
Unless ordered by a court, a copy of this Witness Survey and Declaration will be used for internal
investigation purposes only. It will not be provided to either the complainant or ICM(s) who are the subject
of the complaint.
Due to the potential legal consequences of either suspending or terminating the ICM Agreement of an ICM,
and/or changing upline affiliate(s), the Company recommends you consult with legal counsel prior to talking
with anyone or filing a Witness Statement with the Company. Based upon your signature below, the
Company assumes you make the statements in good faith and believe them to be true.
A person who knowingly makes a false written statement is guilty of a class B misdemeanor. UCA 78B-5-705.