Self-Employment Income Verification Form Page 2

Under penalties of perjury I hereby declare that the above information is true and correct

to the best of my knowledge and belief.

The foregoing instrument was acknowledged before me this _____day of ______________________,

20____ by

__________________________________________________ who is personally known to me

(Name of Affiant)

or who has produced

_____________________________________as identification

and who did /did not (circle one) take an oath.

_____________________________________________

______________________________________

Notary Public Signature

Notary Seal

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Parent category: Legal