1112.9—Sample verification for statement of fact under modified procedure.
State of __________,
County of __________,
SS:
__________ being duly sworn, deposes and says that he has read the foregoing statement, knows the facts asserted there are true and that the same are true as stated.
Signed __________.
Subscribed and sworn to before me this _____ day of __________.
Notary Public of __________.
My Commission expires __________.