JURAT WITH AFFIANT STATEMENT - Notary-NY - Public Notary



JURAT WITH AFFIANT STATEMENT

State of __________________}

} ss.

County of __________________}

( 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

Subscribed and sworn to (or affirmed) before me this _______day of _________________, _______, by

1) _________________________________

2) _________________________________

______________________________________

Signature of Notary Public

Place Notary Seal above

_______________________ OPTIONAL _______________________

Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document.

Further Description of Any Attached Document

Title or Type of Document: _______________________________________________________________

Document Date: ___________________________________ Number of Pages: ___________________

Signer[s] Other than above: _______________________________________________________________

-----------------------

Place Notary Seal above

................
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