THE STATE OF ______ | ||
COUNTY OF ______ | ||
AFFIDAVIT | ||
Before me, the undersigned authority, personally appeared ______, who, being by me duly sworn, deposed as follows: | ||
My name is ______, I am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated: | ||
I am the custodian of the records of ______. Attached hereto are ______ pages of records from ______. These ______ pages of records are kept by ______ in the regular course of business, and it was the regular course of business of ______ for an employee or representative of ______ with knowledge of the act, event, condition, opinion, or diagnosis recorded to make the record or to transmit information thereof to be included in such record; and the record was made at or near the time of the act, event, condition, opinion or diagnosis. The records attached hereto are the original or exact duplicates of the original. | ||
__________________ | ||
Affiant | ||
In witness whereof I have hereunto subscribed my name and affixed my official seal this ______ day of ______, 20______. | ||
__________________ | __________________ | |
(Signed) | (Seal) |
§ 490.692, RSMo