AFFIDAVIT

. State of [STATE/PROVINCE]

City of [CITY]


In consideration of the terms and covenants of this agreement, and other valuable consideration, the parties agree as follows:


RECITALS

BEFORE ME, the undersigned authority, [NAME AND CAPACITY OF OFFICER BEFORE WHOM AFFIDAVIT IS SWORN], on this [DAY OF MONTH] day of [MONTH], [YEAR], personally appeared Affiant, known to me to be a credible person and of lawful age, who being by me first duly sworn, on [HIS OR HER] oath, deposes and says:


[SET FORTH STATEMENT OF FACTS]


IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date first above written.


COMPANY AFFIANT


Authorized Signature Authorized Signature


Print Name and Title Print Name and Title


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AFFIDAVIT