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