I, NAME HERE , being duly sworn declare the following:

My name is XXXXXXXXXXXXXXX, I am 34 years old and I have personal knowledge of the facts in this affidavit. I am a citizen of United States or/ I am a lawful permanent resident A#121-454-787.

then the paragraph of informaion they are giving

Dated: ____________ Signed:


Signed and sworn to before me
this ___ day of _____________, 2012.


_______________________________
Notary Public