Supplementary Affidavit Form

SUPPLEMENTARY AFFIDAVIT FORM

This Supplementary Affidavit is made on this day of , by Affiant Name: (hereinafter "Affiant") and Requested By: (hereinafter "Requesting Party").

RECITALS

WHEREAS, Affiant submitted a prior affidavit, declaration, or testimony in the matter identified below and seeks to provide additional facts and clarification that supplement the prior sworn statement; and

WHEREAS, the Requesting Party has requested a written sworn supplementation to the record for purposes of accuracy, completeness, or to address newly discovered information relevant to the proceeding or administrative matter; and

WHEREAS, the parties intend for this Supplementary Affidavit to be incorporated into the record in the matter specified and relied upon as though originally included with the prior affidavit.

NOW, THEREFORE, in consideration of the foregoing recitals and the mutual covenants contained herein, the parties agree as follows:

1. AFFIANT IDENTIFICATION

1.1 Affiant affirms that the following information identifies the person making this Supplementary Affidavit:

2. REFERENCE TO PROCEEDING

2.1 This Supplementary Affidavit relates to the proceeding identified above and supplements the sworn statements previously filed by Affiant in that proceeding.

3. SUPPLEMENTAL STATEMENT OF FACTS

3.1 Affiant hereby states, under oath, that the following additional facts are true and correct to the best of Affiant's knowledge and belief:

3.2 Each statement set forth in the supplementary facts is offered as sworn testimony and is based upon Affiant's personal knowledge, unless the statement expressly indicates the source of information and belief.

4. EXHIBITS AND EVIDENCE

4.1 Affiant attaches the following documents and physical evidence that corroborate or illustrate the supplementary facts stated above. Check each box that applies and provide a brief description.

5. OATH, CERTIFICATION AND LEGAL CONSEQUENCES

5.1 Affiant declares under penalty of perjury under the laws of the jurisdiction identified in Section 11 that the statements contained in this Supplementary Affidavit and any attached exhibits are true, accurate, and complete to the best of Affiant's knowledge, information and belief. Affiant understands that making a false statement in a sworn affidavit may subject Affiant to civil and criminal penalties, including sanctions for contempt or perjury.

5.2 Affiant acknowledges that this Supplementary Affidavit may be used in the proceeding identified above and consents to its inclusion in the official record.

6. REPRESENTATIONS, WARRANTIES AND COVENANTS

6.1 Affiant represents and warrants that Affiant has the authority and capacity to make this Supplementary Affidavit and that execution of this document does not violate any agreement or obligation to which Affiant is subject.

6.2 Requesting Party represents that it has requested this supplementation for a legitimate procedural or evidentiary purpose and not for any improper or fraudulent aim.

7. NOTICES

7.1 Any notice or communication required or permitted under this Supplementary Affidavit shall be given in writing and delivered to the addresses set forth herein or to such other address as either party designates in writing.

8. AMENDMENTS; WAIVER; COUNTERPARTS

8.1 This Supplementary Affidavit may be amended only by a written instrument signed by both Affiant and Requesting Party. No waiver of any provision shall be effective unless in writing and signed by the party against whom enforcement is sought. This Supplementary Affidavit may be executed in counterparts, each of which will be deemed an original.

9. GOVERNING LAW

9.1 This Supplementary Affidavit shall be governed by and construed in accordance with the substantive laws of the jurisdiction specified below, without regard to conflict of law principles.

10. ENTIRE AGREEMENT; SEVERABILITY

10.1 This Supplementary Affidavit, together with any referenced exhibits, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior understandings and agreements, whether oral or written, relating to that subject matter. If any provision of this Supplementary Affidavit is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

11. EXECUTION

11.1 Each party signing below warrants that it is duly authorized to execute this Supplementary Affidavit. The signatures below constitute sworn affirmation by the Affiant and acknowledgement by the Requesting Party of the terms set forth herein.

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