49 CFR § 1112.9
Sample verification for statement of fact under modified procedure
November 18, 2020
State of __________,
County of __________,
SS:
__________ being duly sworn, deposes and says that he has read the foregoing statement, knows the facts asserted there are true and that the same are true as stated.
Signed __________.
Subscribed and sworn to before me this _____ day of __________.
Notary Public of __________.
My Commission expires __________.
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