The undersigned affirm under penalties for perjury that the foregoing representations and statements are true.
Dated:
Signature
Printed Name
Street Address
City, State, Zip
Telephone Number
Dated:
Signature
Printed Name
Street Address
City, State, Zip
Telephone Number
I affirm under penalties of perjury that the foregoing representations are true.
Petitioner’s signature
STATE OF INDIANA
COUNTY OF
Before me , a notary public, County, State of Indiana, personally appeared and being duly sworn upon his/her oath, says that the facts alleged in the foregoing instrument are true.