Petition To Settle Wrongful Death And Survival Actions Page 5
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105-19-16
V E R I F I C A T I O N
I, _______________________________, am the Petitioner in this action and hereby verify
that the statements made in the foregoing Petition to Settle or Compromise Minor's Action are true
and correct to the best of my knowledge, information and belief.
I understand that the statement in said Petition are made subject to the penalties of 18 Pa. C.S.
§4904 relating to unsworn falsification to authorities.
DATE: ______________________
_______________________
PETITIONER
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