Form 43 - Certification Pursuant To 22nycrr 130-1.1-A

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Certification Pursuant to 22NYCRR 130-1.1-a (Form 43)
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[1. Index No. & Year] Insert Index Number & the year it was purchased
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[2. Fill in name(s)] Fill in the Plaintiff/Petitioner name
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[3. Fill in name(s)] Fill in the Defendant/Respondent Name
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[4. Date]
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[5. Sign name before a notary public] Signature
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[6. Print Name] Print Name
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[7. Affidavit must be notarized.] Sign affidavit before a notary public

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