Petition Discontinuance Of Treatment Page 3
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3Form 7-11 page 3
VERIFICATION
(Agency)
STATE OF NEW YORK
)
) ss.:
COUNTY OF_______________________ )
_________________________________________, being duly sworn,
deposes and says:
That (s)he is the______________________________ of ____________________,
an agency authorized to originate the above- entitled proceeding, and is acquainted with the facts
and circumstances therein; that (s)he has read the foregoing and knows the contents thereof; that
the same is true to (his) (her) own knowledge, except as to matters therein stated to be alleged on
information and belief and as to those matters (s)he believes it to be true.
_____________________________
Name
_____________________________
Title
Sworn to before me this_____ day of _________________, _____ .
________________________________________ Notary Public
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