Civil Rights Complaint Page 12

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DECLARATION UNDER PENALTY OF PERJURY
The undersigned declares under penalty of perjury that he/she is the plaintiff in the above
action, that he/she has read the above complaint, and that the information contained therein is true
and correct. 28 U.S.C. §1746; 18 U.S.C §1621.
Executed at
on
20___.
(Location)
(Date)
Signature

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