AFFIDAVIT

STATE OF ________(1)_______)

SS:

COUNTY OF ______(2)________)

KNOW ALL YE MEN BY THESE PRESENTS,

That on this _(3)__ day of ______(4)_________, 19_(5)_, personally came and

appeared before me ______(6)__________, of __________(7)_______________, known, and
known to me, who after being first duly sworn, deposes and says:

(Insert Sworn Statement)

FURTHER AFFIANT SAYETH NOT.

__________(8)____________

SUBSCRIBED TO AND SWORN TO before me this ___(9) day of____(10)

____________, ___(11)_.

_____________(12)__________
NOTARY PUBLIC

My Commission Expires __(13)__

NOTICE

The information in this document is designed to provide an outline that you can follow
when formulating business or personal plans. Due to the variances of many local, city, county
and state laws, we recommend that you seek professional legal counseling before entering into
any contract or agreement.