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Prescribed by the County Form 170 <br />State Board of Accounts <br />(2005) <br />Declaration <br />This form Is to be signed by the prepa�er of a document and recorded with each document In accordance <br />with IC 36-2-1.5-5(a). <br />I, the undersigned preparer of the attached document,.(n accordance with IC 36-2-7.5, do hereby affirm <br />under the penalties of perjury: <br />1, t have reviewed the,attached docurent for the purpose of identifying and, to the extent permlhed <br />by Saw, 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 />I, the undersigned, affirm under the penalties of perjury, that the foregoing declarations are true. <br />Signature of Declarant <br />Printed Name of Declarant <br />COUr,ITY OF ST.!OSEPH, !i\01ANA <br />i t)nreby csrtify Ihiat this is ? true <br />- id cor,• oicte cope ci Li o cF�2 <br />clot : nt Gn---4x i l t;�`, ] ` i;,e� <br />:thlake, /ou41 oReGo- er <br />This Certification Stamp Replaces <br />Our Previous Certification System, <br />Effective i-jS ; <br />0604726 <br />