Author: eeo21b
Company: EEO 21

WITNESS AFFIDAVIT

	Date: 

Re:	??? vs. ???
	Case No: ???

1.	My name is: 

2.	My address is: 

3.	My phone numbers are: 

I have witnessed the following on the date specified: 

4.	

5.	

6.	

(Use back page or attachment if necessary.  Initial each page. Place the Declaration, below, on the last page. )

DECLARATION

I, the undersigned, declare under penalty of perjury that the statements made in the above affidavit are true and correct to the best of my knowledge, information, and belief.  They are made voluntarily and without any benefit (actual or promised) offered in exchange for making these statements.

(sign)__________________________		______________
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