CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE § 8202

[Pages:2]CALIFORNIA JURAT WITH AFFIANT STATEMENT

GOVERNMENT CODE ? 8202

See Attached Document (Notary to cross out lines 1?6 below) See Statement Below (Lines 1?6 to be completed only by document signer[s], not Notary)

1_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

4_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

5_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

6___________________________________________________ Signature of Document Signer No. 1

____________________________________________________ Signature of Document Signer No. 2 (if any)

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of California County of ______________________

Subscribed and sworn to (or affirmed) before me

on this ________ day of _________________, 20_____,

by

Date

Month

Year

(1)______________________________________________

(and (2)________________________________________ ), Name(s) of Signer(s)

proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.

Signature _______________________________________ Signature of Notary Public

Seal Place Notary Seal Above

OPTIONAL Though this section is optional, completing this information can deter alteration of the document or

fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: ________________________________________ Document Date: ________________ Number of Pages: _____ Signer(s) Other Than Named Above: _________________________________________

?2014 National Notary Association ? ? 1-800-US NOTARY (1-800-876-6827) Item #5910

California Jurat With Affiant Statement

If no other format is prescribed, this form may be used when an individual is signing and swearing (or affirming) that certain written statements are true.

The text space provided (lines 1?5) are available for a document signer to type or neatly print (in ink) a written statement. This portion of the certificate should not be completed by the Notary. A person completing any of lines 1?5 must sign this form on line 6 in the presence of the Notary, who would also administer an oath or affirmation.

If this form is to be attached to another document, then the Notary should cross out lines 1?6. The signer would affix a signature on the attached document, not on this certificate, in the Notary's presence.

The optional section at the bottom can deter alteration of the document or fraudulent reattachment of this form to an unintended document. The insertions in this section are not required by law. Failure to fill out this section will not affect the validity of the jurat certificate.

Instructions:

1 DOCUMENT OPTION. Check the first box if this Jurat certificate is going to be attached to another document. If so, then cross out lines 1?6 on certificate. Check the second box if the affiant is going to use this form to make a statement.

2 AFFIANT STATEMENT. These lines are provided for the affiant to complete his or her own statement, and should not be completed by the Notary. If affiant is not using this certificate to make a statement, lines 1?6 should be crossed out by the Notary.

3 SIGNATURE(S) OF AFFIANT(S). This is signed by the person(s) who completed the statement in lines 1?5. If an attached document is signed instead, these spaces should be lined through by the Notary.

4 NAME OF COUNTY where Notary performs notarization.

CALIFORNIA JURAT WITH AFFIANT STATEMENT

GOVERNMENT CODE ? 8202

1 X See Attached Document (Notary to cross out lines 1?6 below) See Statement Below (Lines 1?6 to be completed only by document signer[s], not Notary)

2 1_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2____________________________________________________________________

3____________________________________________________________________

4____________________________________________________________________

5___________________________________________________________________

3 6___________________________________________________ Signature of Document Signer No. 1

____________________________________________________ Signature of Document Signer No. 2 (if any)

4 State of California

County of ______L_o__s___A_n__g_e_l_e_s__

9

hfulness, accuracy, or validity of that document.

5

Subscribed and sworn to (or affirmed) before me

6 on this __1_4_t__h__ day of _______J_u_n__e______, 20_1_4___,

by

Date

Month

Year

7 (1)_____________T_e__r_r_y___S_m___it__h___________________

(and (2)________________________________________ ), Name(s) of Signer(s)

7 proved to me on the basis of satisfactory evidence

to be the person(s) who appeared before me.

8 Signature _______________________________________ Signature of Notary Public

Seal Place Notary Seal Above

OPTIONAL Though this section is optional, completing this information can deter alteration of the document or

fraudulent reattachment of this form to an unintended document.

10 11 Description of Attached Document

Title or Type of Document: ___A__f__f_i_d_a__v_i_t___o__f___L_o__s__s_____________ Document Date: ____N_o___D__a_t__e___

12 13 Number of Pages: _O_n_e__ Signer(s) Other Than Named Above: _____N__o___O__t_h__e_r___S__ig__n__e_r_s______________

8 SIGNATURE OF NOTARY, exactly as name appears on commissioning papers and in seal.

9 NOTARY SEAL IMPRINT, clearly and legibly affixed.

SPACES 10?13 ARE OPTIONAL. Omission of information here will not affect the document's validity. However, completing these spaces can deter alteration of the document or fraudulent reattachment of this form to an unintended document.

10 TITLE OR TYPE OF DOCUMENT notarized, such as "Affidavit of Loss."

11 DATE OF DOCUMENT notarized. If the certificate is being attached to a document, most, but not all, will have a date, usually at the top or following the signature. If none, insert "No Date."

5 `SWORN TO' OR `AFFIRMED.' If the affiant takes an oath, cross out "(or affirmed)." If the affiant takes an affirmation, cross out "sworn to (or".

?2014 National Notary Association ? ? 1-800-US NOTARY (1-800-876-6827) Item #5910

12 NUMBER OF PAGES in the notarized document. This may point out fraudulent addition or removal of pages. If the certificate is being attached to a document, do not count it as a page. If

6 DATE OF NOTARIZATION. Actual day, month and year in which

the certificate is the document, page count would be "One."

the document signer appears before Notary to sign this certificate or an attached document and take an oath or affirmation.

13 SIGNER(S) OTHERTHANNAMEDINSPACE(S) 7. Since all affiant signers might not be named on the same Notary certificate,

7 NAME(S)OF AFFIANTSIGNER(S) name(s) signed before the Notary. Initials and spelling of name(s) should agree with document, ID

card and journal signatures. If only one signer is appearing before the

Notary, cross out letters that do not apply -- for example, "(and," ")," and

insert name(s) of signer(s) here that appear(s) or will appear on other certificates -- as many as space allows. If none, insert "No Other Signers."

the "s" in name(s), signer(s), person(s) -- and cross or line through the

second space to prevent later unauthorized insertion of a name.

National Notary Association

9350 De Soto Avenue ? Chatsworth, CA 91311-4926 ? 1-800-876-6827 ?

?2014 National Notary Association

Item #5910

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