The written stipulations and agreements to court jurisdiction required by this code shall be in the following format:

Stipulation to Court Jurisdiction

The undersigned hereby expressly recognizes that the benefit sought or presently enjoyed by the undersigned from the Osage Nation government, to wit: (Insert description of benefit whether it be a license, permit, contract, rental, lease, or otherwise) is a privilege and a benefit to the undersigned and not a property interest or matter of right. In consideration of, and as a condition precedent to, the grant, issuance or continued enjoyment of this privilege and benefit, regardless of whether the undersigned is a natural or artificial person or entity, and further regardless of whether the undersigned is of Indian or non-Indian blood, descent or legal character, the undersigned hereby stipulates and agrees that jurisdiction over all matters and disputes arising out of the exercise of such a benefit and privilege shall vest in the Court of Indian Offenses until such time as the Osage Nation Courts lawfully assume such jurisdiction, and that thereafter exclusive jurisdiction shall vest in the Osage Nation Courts. The undersigned further stipulates to be bound by all Osage Nation codes governing such benefits, privileges and activities. The undersigned further expressly waives all future rights to contest the jurisdiction of the Court of Indian Offenses or the Osage Nation Courts over any such matters, disputes, actions or decisions of any branch of the Osage Nation government.

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Signature and title, if applicable

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Date