VERIFICATION
I, _______________, hereby state that the facts above set forth are true and correct (or are true and correct to the best of my knowledge, information and belief). I understand that the statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities).
Date: _______________
_______________
(Signature)
AFFIDAVIT
I, _______________, being duly sworn do hereby affirm according to law, depose and say that the facts above set forth are true and correct to the best of my knowledge, information and belief.
_______________
(Signature of affiant)
Sworn and subscribed before me this _______________ day of _____, 20 ____.
_______________
(Notary Public)
7 Pa. Code § 179.106