The statement required by this subdivision shall be directed to the court having jurisdiction of the alleged violation, shall be affirmed as true under penalty of perjury, and shall include the name, occupation and position of the person making the statement, the time and date that the repairs or inspection were made and a statement that the defective equipment, cited in the violation, on the vehicle in question, is in proper working order.
N.Y. Comp. Codes R. & Regs. Tit. 17 § 820.10