|Prescribed by the||County Form 170|
State Board of Accounts
This form is to be signed by the preparer of a document and recorded with each document in accordance with IC 36-2-7.5-5(a).
I, the undersigned preparer of the attached document, in accordance with IC 36-2-7.5, do hereby affirm under the penalties of perjury:
1. I have reviewed the attached document for the purpose of identifying and, to the extent permitted by law, redacting all Social Security Numbers;
2. I have redacted, to the extent permitted by law, each Social Security number in the attached document.
I, the undersigned, affirm under the penalties of perjury, that the foregoing declarations are true
Signature of Declarant
Printed Name of Declarant
No guidelines are available for this form at this time.