VERIFICATION
I, ________________ , hereby state that the facts above
set forth are true and correct (or are true and correct to the best of my knowledge, information and belief). I understand that the statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities).
___________________
Date
___________________
Signature
___________________
Printed Name
AFFIDAVIT
I, ___________ (Affiant), being duly sworn (affirmed) according to law, depose and say that (I am authorized to make this affidavit on behalf of _____________ corporation/business entity, being the holder of the office of _______________ with that corporation/business entity, and that the facts above set forth are true and correct (or are true and correct to the best of my knowledge, information and belief).
____________________
(Signature of affiant)
Sworn and subscribed before me this _____day of
______,20 ____.
(Signature of official administering oath)
28 Pa. Code § 1230a.45