00756569-1

STATE OF GEORGIA )
)
COUNTY OF _________________ )

The undersigned hereby affirms that the request for booking/mug shot
photographs on behalf of the ____________________________ newspaper is solely
for the purpose of news gathering and reporting. The undersigned affirms on behalf of
the __________________ newspaper that no charge or other consideration will be
imposed on any person in return for removing such a photograph from the newspapers
print or electronic publication or web site.
This _____ day of ____________________, 20___.

______________________NEWSPAPER

BY: ___________________________
ITS:____________________________

Sworn to and subscribed before
me, this ___day of ____________, 201__.

______________________________
Notary Public

(Seal)