The undersigned , having first been duly sworn and placed under oath and penalty of perjury, hereby states that, except where qualified as being based upon information and belief, I know the following to be true:
- I am of legal age and am otherwise competent to give this affidavit.
- I currently reside at , , , .
Sworn to and subscribed before me, this ______________ _____, ________
||Print Name: ___________________________|
Dated: ______________ _____, ________.