Form H4-0043 - Affidavit
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1AFFIDAVIT
STATE OF TENNESSEE
COUNTY OF _________________
NAME OF FACILITY: ___________________________________________________
CON No. _____________________
I, ______________________, after first being duly sworn, state under oath that I am
the contact person named in this Certificate of Need application or the lawful agent
thereof, hence stating that the original Certificate of Need being lost/misplaced do at
this time request a replacement Certificate of Need, and do state this a is true,
accurate, and complete statement and further state that if found the original Certificate
of Need will be submitted to the Tennessee Health Facilities Commission's office.
_____
Signature/Title
Sworn to and subscribed before me, a Notary Public, this the _____ day of _________, 20__,
.
witness my hand at office in the County of ________________________, State of Tennessee
_____
NOTARY PUBLIC
My commission expires
, _______.
H4-0043
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Parent category: Financial