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s <br />Prescribed by the <br />State Board of Accounts <br />(2005) <br />Declaration <br />County Form 170 <br />This form Is to be signed by the prepa�er of a document and recorded with each document in accordance <br />with IC 36-2-7.5-5(a), <br />I, the undersigned preparer of the attached document,.ln accordance with IC 36-2-7.5, do hereby affirm <br />under the penalties of perjury: <br />1, 1 have reviewed the- attached document for the purpose of identifying and, to the extent 'permltted <br />by law, redacting all Social Security numbers; <br />2. 1 have redacted, to the extent permitted by law, each Social Security number In the attached <br />document. <br />1, the undersigned, affirm under the penalties of perjury, (hat the foregoing declarations are true. <br />A resident of St. Joseph County, Indiana. <br />My Commission Expires: <br />Signature of Declarant <br />( 4 /i r._ �SS <br />Printed Name of Declarant <br />` ' i Z V U 6 <br />This instrument was prepared by Aladean DeRose, Assistant City Attorney, 1400 County -City Building, South Bend, Indiana <br />46601. <br />F:IDATA\Si-IAREIENGINEERI W PDATA\CONSENTCOM i a.wpd <br />