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Prescribed by the County Form 170 <br />State Board of Accounts <br />(2005) <br />Declaratlon <br />This form Is to be signed by the prepa'rer 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'permlhed <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, that the foregoing declarations and true. <br />Signature 6f Declarant <br />Printed Name of Declarant <br />