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Sworn Statement Map V5

Date: 
08/2022
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 Office of the Chief Information Officer website on December 07, 2022 at 10:17am.