Form Psc 17 - Common Carrier Pipeline Annual Report Page 8

AFFIDAVIT

STATE OF

)

) ss.

County of

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I, the undersigned, on oat do say that the foregoing return and any accompanying schedules have been prepared

from the original books, papers and records of _________________________________________________ Company;

that I have carefully examined the same; and declare the same to be a complete and correct statement of the business

and affairs of the said company in respect to each and every matter ant thing set forth, to the best of my knowledge and

belief; and I further say that no deductions were made before stating the gross earnings or receipts herein set forth,

except those shown in the foregoing accounts.

(Signature)

(Official Title)

SUBSCRIBED AND SWORN to before me at

this __________ day of _________________, ______________ .

(Notary Public)

(Name printed or typed)

My Commission Expires:

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Parent category: Financial