I, ______________, have read and understand the provisions of the false swearing statute. I hereby certify under penalty of false swearing that the foregoing claim, including all of its attachments, if any, is true and accurate.
______________________ | ______________________ |
Signature of Claimant | Date |
______________________ | |
Printed Name of Claimant |
STATE OF WYOMING | ) | |
) | ss. | |
COUNTY OF _____________ | ) |
Subscribed and sworn to before me, a Notarial Officer, this ... day of ....., ....
______________
Notarial Officer
My Commission Expires: (Seal).
W.S. 1-39-113