THIS INSTRUMENT HEREBY ACKNOWLEDGES that the undersigned, [name], ("affiant"), residing at [address, city and state], is of legal age, and does hereby swear and affirm that the following is true and accurate, to the best of [his/her] knowledge, under penalty of perjury: [list facts to be attested to] Signed to this [day] day of [month], [year]. _______________________________________Signature of Affiant_______________________________________Print Name of Affiant_______________________________________ _______________________________________ _______________________________________AddressSTATE OF _____________________ COUNTY OF ____________________ In _______________, on the _____________ day of ____________, 19___, before me, a Notary Public in and for the above state and county, personally appeared _____________________________________________, known to me or proved to be the person named in and who executed the foregoing instrument, and being first duly sworn, such person acknowledged that he or she executed said instrument for the purposes therein contained as his or her free and voluntary act and deed. Type of ID Produced: _________________________Affiant __ is __ is not personally known to me_______________________________ NOTARY PUBLICMy Commission Expires: ________(SEAL) ...
