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Submit Testimony

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)

Declarative Statement

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

Phone Number

E-mail (required)

(SPECIAL NOTE: STATUTE DOES NOT REQUIRE NOTARY]

By submitting this content you agree to allow CCASurvivors.com to use this information for publishing, investigative purposes or for use in rescue efforts. By submitting these statements you assert that the allegations expressed are true and reported from first hand experience. You acknowledge that it is your responsibility to fully investigate any unsubstantiated claims and grant waiver to further investigation or validation of claims by CCASurvivors.com. You have the right to remain anonymous, and your contact information will never be used or posted without your expressed permission.