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NOTICE: THIS FORM CONTAINS SENSITIVE DATA.

Unsworn Declaration (Texas Civil Practice and Remedies Code, Section 132.001) My name is: rvea/Ai/) \)Or4r~, Jh*rr\()SC>Al iQ.

First ft Middle t I iLast

my date of birth is: Month / i ^ i fin.

Day Year and

my address is: 11*30 FM ^W J^kshofi-T) TtXfiS lUStf Street Address City State Zip Code and J/iak.

Country My email address is _ ML (If you are incarcerated, you must also include the following information.)

My inmate identifying number, if any, is: D ( <?<P\~1<f)~U7„ I am presently incarcerated in: \_mctseij <>t/}f-r. J/}/'I IJaji'I (f Corrections Unit Name in: City MAP County JflfiC Tex/E.s IMS*.

State Zip Code

declare under penalty of perjury that all information in the attached document titled, , is true and correct. pi Name ofDocument & Signed in A }*r(< County .County, l-ckfl <, State on this date: i i // i hr Month Day Year

Your Signature

Pursuant to Texas Civil Practice and Remedies Code Section 132.001, an unsworn declaration may be used in lieu of a written sworn declaration, verification, certification, oath, or affidavit required by statute or required by a rule, order, or requirement adopted as provided by law. This provision does not apply to an oath of office or an oath required to be taken before a specified official other than a notary public. An unsworn declaration made under this section must be 1) in writing, 2) signed by the person making the declaration as true under penalty of perjury and 3) in substantially the form used above.

)TexasLawHelp.org - Unsworn Declaration, August 2012 Page 1 of 1