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Sworn Statement Map V5

Document Text Version

IA Location ID _________________________________
Street Address _________________________________
Unit Number __________________________________
City, State, Zip _________________________________
Resident Name ____________________________________
Date ______________________
Resident Signature ____________________________________________________________

By signing this form, I certify, under penalty of perjury, that I am the resident or business owner at the address listed
above, and that any statement and representations made in this form are true and accurate.

Printed from the website on December 03, 2023 at 11:10am.