STATE OF TENNESSEE
COUNTY OF
This the ____________________day of ____________________, 20____________________.
FURTHER AFFIANT SAITH NOT
Please Print: ____________________
Signature: ____________________
Sworn to and subscribed before me this ____________________ day of ____________________, 20____________________.
Please Print: ______________
Judge of the ______________ Court for
______________ County, Tennessee
Signature: ____________________
T.C.A. § 36-1-117