DECLARATION UNDER PENALTY OF PERJURY
PURSUANT TO 28 USCA 1746
I, declare and state as follows:
Name of Program
Location of Program
Period of Internment (MM/YY to MM/YY)
I give CCASurvivors.com permission to use this statement. I declare under penalty of perjury that the foregoing is true and correct. Executed on(date: MM/DD/YY)
Name of Declarant
Address of Declarant
(SPECIAL NOTE: STATUTE DOES NOT REQUIRE NOTARY]
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