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Jurat with Affiant Statement

I (we), ________________________________________________________________________________ with my (our) signatures, herewith swear (or affirm) that the following statement is true to the best of my (our) knowledge.

Initial each line completed

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

1. _____________________________________________________________________ 2. _____________________________________________________________________ 3. _____________________________________________________________________ 4. _____________________________________________________________________ 5. _____________________________________________________________________ 6. _____________________________________________________________________ 7. _____________________________________________________________________ 8. _____________________________________________________________________ 9. _____________________________________________________________________ 10. _____________________________________________________________________ 11. ______________________________________

Signature of affiant Date signed

State of California County of _________________

______________________________________

Signature of affiant Date signed

Subscribed and sworn to (or affirmed) before me on this ________ day of ______________________, 20_____ by ______________________________________________________________________, proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.

________________________________________ Notary Public Signature

(Notary Seal)

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