Modèle:SwornSignature-JP

SWORN/AFFIRMED TO at [city], in the region of
[region], Province of
[province], this [day]
day of [month], 20____, before me:

________________________________

Commissioner of Oaths/Justice of the Peace
for the province of [province]

)
)
)
)
)
) _____________________________
) [Affiant Name]
) [Affiant title]
)