I, <Full Name>, do under oath depose and say:
I am over the age of eighteen years.
<Body of Statement.>
I affirm the statements above to be true to the best of my knowledge and belief.
IN WITNESS WHEREOF, and under penalty of perjury under the laws of the State of <State>, I affix my hand this <Day> day of <Month>, <Year>.
STATE OF <State>, COUNTY OF <County>, ss.:
I, __________________________________, do hereby certify that on this
______ day of ________, __________, personally appeared before me
known to be the person(s) who executed the foregoing instrument.
Notary Public in and for the State of _________________.
My commission expires _______________.