State of __________,
County of __________,
SS:
__________ being duly sworn, deposes and says that he has read the foregoing statement, knows the facts asserted there are true and that the same are true as stated.
Signed __________.
Subscribed and sworn to before me this _____ day of __________.
Notary Public of __________.
My Commission expires __________.
49 C.F.R. § 1112.9