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Title 5

PART 1201 APPENDIX IV

Appendix IV to Part 1201 - Sample Declaration Under 28 U.S.C.1746

5:3.0.1.1.2.8.41.6.4 : Appendix IV

Appendix IV to Part 1201 - Sample Declaration Under 28 U.S.C.1746 Declaration

I, ___________, do hereby declare:

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

Executed on Date Signature