Fill and Sign the Affidavit Delivery Form

Affidavit of Transmittal by Courier of Private Delivery Service STATE OF ____________________ COUNTY OF _______________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, ____________________ (Name of Affiant) , who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. I am over the age of ____________________ (age of majority) , and, on ____________________ (date) , I transmitted the ______________________________ (description of the paper or document) , a copy of which is attached, to the addressee set forth below, by depositing a copy enclosed in the prescribed wrapping of ____________________ (name of private courier service) , at the office of ____________________ (name of private courier service) , located at ___________ ______________________________________ (street address, city, state, zip code) , addressed as follows: ____________________ (Name of Addressee) , ____________ _________________________ (street address, city, state, zip code) . 2. A true and correct copy of the receipt for delivery charges of ________________ ____________ (name of private delivery service) for the delivery of above-described ____________________________ (description of paper or document) is attached to this instrument. ___________________________________ (Printed Name of Affiant) ___________________________________ (Signature of Affiant) SWORN to and subscribed before me, this the ____ day of _____________, 20____. _____________________________ NOTARY PUBLIC My Commission Expires: ___________________