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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:

  1. I am of legal age and am otherwise competent to give this affidavit.

  2. I currently reside at , , , .

  3. Sworn to and subscribed before me, this ______________ _____, ________

    Signature: ___________________________ Print Name: ___________________________

    Dated: ______________ _____, ________.


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