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)
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, being the holder of the office of ___ with that corporation,) 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)
58 Pa. Code § 495a.5