Form 2020 - Con Determination Form Relocation Of A Health Care Facility Page 3

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Page 3 of 3
7/23/15
SECTION V. AFFIDAVIT
(Each Petitioner must submit a completed Affidavit.)
Petitioner: _____________________________________________________________
Project Title: ___________________________________________________________
I, _____________________________________, ______________________________
(Position – CEO or CFO)
(Name)
of ____________________________________being duly sworn, depose and state that the
(Organization Name)
information provided in this CON Determination form is true and accurate to the best of my
knowledge.
__________________________________________
_________________________
Signature
Date
Subscribed and sworn to before me on______________________________________
_____________________________________________________________________
Notary Public/Commissioner of Superior Court
My commission expires: __________________________________________________
Form 2020
Revised 08/11

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