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�r <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 preparer 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, in 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 permitted <br />by iaw, 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 forgoing declarations are true. <br />� Ltcw� <br />Signature of Declarant <br />Shawn E. Peterson <br />Printed Name of Declarant <br />