State of
County of
I, , being of legal age, residing at , being duly sworn, do hereby declare and state as follows:
Under the penalty of perjury, I hereby declare and affirm that the above-mentioned statement is true and correct to the best of my knowledge.
This Affidavit was made on .
______________________
State of
Acting in the county of
Sworn to and subscribed before me on ___________________________.
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Place for signature
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Notary public's name and seal