Statutory Declaration

I, of

do solemnly and sincerely declare as follows:

And I make this solemn declaration conscientiously believing the same to be true and by virtue of the provisions of the Act.

Declared at on

Signature of Declarant:

Notarization

Subscribed and sworn before me at

            this  day of , 20
        

Signature & Seal of Notary Public / Commissioner for Oaths: