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Undersigned

I, the undersigned, certify that the information given by me ...

1. (If Applicable, initial here____) SOCIAL SECURITY MEDICARE (NONHMO) I, the undersigned, certify that the information given by me and applied under TITLE XVIII of the Social Security Act is correct.

I, the undersigned

AFFIDAVIT I, the undersigned ROBIN WOOD hereby make oath and state as follows: 1. The facts deposed to in this affidavit are within my personal knowledge and are true and correct.

The undersigned, being first duly sworn, on oath says that:

DECLARATION OF LOST, STOLEN OR DESTROYED TELLER'S OR CASHIER'S CHECK The undersigned, being first duly sworn, on oath says that:

Personally appeared before me, the undersigned Notary Public ...

EXHIBIT F STATE OF _____ COUNTY OF _____ AFFIDAVIT OF _____ Personally appeared before me, the undersigned Notary Public in and for said County and State, _____, who after first being duly sworn, deposes and says on oath as follows: 1.

We, the undersigned, do hereby agree to the terms of the ...

4-H-869-W R EVISED 12/10 (For use in leasing dairy heifers, horses, and llamas.) Colleen Brady, Youth Extension Specialist, and Mark Russell, Extension Animal Specialist We, the undersigned, do hereby agree to the terms of the lease involving Animal's Name _____ Breed _____ Sex___ Reg ...

I, the undersigned, declare as follows: 

FPR­26 ­03 DECLARATION OF DUE DILIGENCE ATTORNEY OR ARTY WITHOUT ATTORNEY ( Name, state bar number, and dress ): TELEPHONE NO: FAX ATTORNEY FOR ( Name ): SUPERIOR COURT OF CALIFORNIA • COUNTY OF FRESNO 1100 Van Ness Avenue Fresno, California 93724­0002 Guardianship Con ser vat or ship ...

S PORTS M EDICINE D EPARTMENT M EDICAL E XAMINATION & A ...

... the undersigned, hereby acknowledge, affirm, and represent the following: A. PRESENT PHYSICAL CONDITION: I have previously warranted and represented to Louisiana Tech University “LA Tech”( ) ...

W E, THE UNDERSIGNED, REQUEST THAT THE G OVERNOR,A ...

we, the undersigned, request that the governor,administration, and legislature of the state of new jersey formally commit to reinvesting all federal medicaid matching funds for the division of

This is to certify that I, the undersigned, hereby consent to ...

This is to certify that I, the undersigned, hereby consent to and authorize the disclosure of any medical information to the following:

Before me, the undersigned Notary Public, on this day ...

AFFIDAVIT STATE OF TEXAS § § COUNTY OF _____ § Before me, the undersigned Notary Public, on this day personally appeared _____, known to me, who being by me duly sworn upon his/her oath, deposed and said: 1.