STATE OF NEW YORK)
..) SS.:...............................................................................
COUNTY OF.. )..............................................................
______, being duly sworn, deposes and says that he is______ in this appeal; that he has read the annexed ______ and knows the contents thereof; that the same is true to the knowledge of deponent except as to the matters therein stated to be alleged on information and belief, and as to those matters he believes them to be true.
(Signature)
Subscribed and sworn to before me this
.................................................................
day of
19
(Signature and title of officer)
N.Y. Comp. Codes R. & Regs. Tit. 8 § 113.15