STATE OF <state>
COUNTY OF <county>

I, the undersigned, declare that I am a <type of party you are to the lawsuit> in the above-entitled action. I have read the foregoing <title of document you are verifying> and know the contents thereof. The contents of said document are true to the best of my knowledge, except as to the matters which are therein stated upon my information and belief, and as to those matters, I believe them to be true.

I declare under penalty of perjury, under the laws of the State of <state>, that the foregoing is true and correct.

Executed this ______ day of ____________________, _______, at <city>, <state>.

<your name>

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