49 CFR § 1112.9 - Sample verification for statement of fact under modified procedure.

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 __________.