"Affidavit of Publication Under Section (specify applicable section) of the Limited Liability Company Law State of New York, County of ________, ss.:
The undersigned is the printer (or publisher) of ______________ (name of newspaper), a _________ (daily or weekly) newspaper published in ________________, New York. A notice regarding _______________ (name of limited liability company) was published in said newspaper once in each week for six successive weeks, commencing on __________ and ending on ________. The text of the notice as published in said newspaper is as set forth below, or in the annexed exhibit. This newspaper has been designated by the Clerk of ________ County for this purpose.
____________ (signature)
__________(printed name),
(jurat)"
The text of the notice set forth in or annexed to each affidavit of publication shall:
"Certificate of Publication of ______ (name of limited liability company) Under Section ______ (specify applicable section) of the Limited Liability Company Law
The undersigned is the _________ (title) of ___________ (name of limited liability company). The published notices described in the annexed affidavits of publication contain all of the information required by the above-mentioned section of the Limited Liability Company Law. The newspapers described in such affidavits of publication satisfy the requirements set forth in the Limited Liability Company Law and the designation made by the county clerk. I certify the foregoing statements to be true under penalties of perjury.
Date
Signature
Printed Name"
N.Y. Limited Liability Company Law Law § 102