KNOW ALL YE MEN BY THESE PRESENTS,
That on this ___ day of ______________, 19__, personally came and appeared before me _______________ of _________________________, known and known to me who after being first duly sworn, deposes and says:
(Insert Sworn Statement)
FURTHER AFFIANT SAYETH NOT.
SUBSCRIBED TO AND SWORN TO before me this ___ day of________________, 19__.
My Commission Expires on
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