Fill and Sign the In the Circuit Court of Mississippi State of Mississippi V Case No Form

IN THE CIRCUIT COURT OF COUNTY, MISSISSIPPI PLAINTIFFVS. NO. and DEFENDANTS AFFIDAVIT STATE OF MISSISSIPPICOUNTY OF PERSONALLY came and appeared before me, the undersigned authority in and for the jurisdiction aforesaid, , ("Affiant"), who, having been duly sworn by me, states under oath the following, to-wit: 1. I am an adult resident citizen of County, Mississippi having personal knowledge of the matters stated herein and being competent to testify to those matters.2. I am not a resident of County, Mississippi and have not been a resident of 2222 County, Mississippi since . I am now, and have been since , a resident of County, Mississippi, with my home address of , , Mississippi 2.3.On , 20 , I interpreted an x-ray of ’s and prepared a report reflecting my interpretation of that x-ray. A true and correct copy of that report is attached hereto as Exhibit " ". At that time, I was providing radiological services at in , Mississippi. My interpretation of that x-ray was performed and my report prepared in , County, Mississippi. At no time have I provided any radiological or other medical services, care or treatment to in County, Mississippi.FURTHER AFFIANT SAYETH NOT.________________________ SWORN TO AND SUBSCRIBED before me, this day of , ._________________________________________NOTARY PUBLICMy Commission Expires: