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Producer affidavit form Producer Affidavit Market Swine Health Record Youth Producer Name Address Premise ID if available Phone QA Certification Fair Fair Tag Sale Date C1055E Herd Tag / Ear Notch ID Sex Birth Date Breed/Color I original producer attest through first-hand knowledge normal business records or producer affidavit s that the animal referenced to by this document is of country origin and is delivered to Youth Producer. Date Purchased Purchased From Farm Name Office Phone Producer Signature Print Name If you need additional space for treatments or medicated feeds use supplemental health form page available at animalag. wsu. edu- Youth Producers. Treatments Dewormers Date Time Condition Being Treated Estimated Weight Treatment Administered Medication dispensed amount and route of administration Drug Lot Number Name Person giving Withdrawal Time Complete Instructed For prescription or extra label drug use list the veterinarian s name address and phone. Medicated Feeds Remember to document ALL medicated feeds and withdrawal times. Medication Name Dates Fed Medication included in feed and approximate amount of medication Produce healthy and safe pork products by being a knowledgeable and responsible producer. I certify that I produced this animal and I have listed ALL products and treatments they received while in my care/ownership and all withdrawal times have been met. I attest that the animal referred to by this document is of country origin and raised in country. Give Subcutaneous Sub-Q injections under loose skin of neck or flanks using the tented method. Give Intramuscular IM injections in the neck. If label indicates a choice use Sub-Q under the skin injections over IM. NEVER inject into the ham or the loin area* Youth Signature Date Guardian Signature Date Authors Sarah M. Smith Jean Smith and Jan Busboom* C1055E revised November 2008. WSU Extension programs and employment are available to all without discrimination* Evidence of discrimination may be reported through your local WSU Extension Office. The information given herein is for educational purposes only. References to commercial products or trade names are made with the understanding that no discrimination is intended and no endorsement by WSU Extension is implied*. Date Purchased Purchased From Farm Name Office Phone Producer Signature Print Name If you need additional space for treatments or medicated feeds use supplemental health form page available at animalag. wsu. edu- Youth Producers. Treatments Dewormers Date Time Condition Being Treated Estimated Weight Treatment Administered Medication dispensed amount and route of administration Drug Lot Number Name Person giving Withdrawal Time Complete Instructed For prescription or extra label drug use list the veterinarian s name address and phone. wsu. edu- Youth Producers. Treatments Dewormers Date Time Condition Being Treated Estimated Weight Treatment Administered Medication dispensed amount and route of administration Drug Lot Number Name Person giving Withdrawal Time Complete Instructed For prescription or extra label drug use list the veterinarian s name address and phone. Medicated Feeds Remember to document ALL medicated feeds and withdrawal times. Medication Name Dates Fed Medication included in feed and approximate amount of medication Produce healthy and safe pork products by being a knowledgeable and responsible producer.

Affidavit existence form Harris County Appraisal District 13013 Northwest Fwy. P. O. Box 922007 Houston TX 77292-2007 713 957-7800 Form A/P 10/10 Affidavit Statement of Use Sale Non-existence of Property or Discontinuance of Business Instructions This form is to be used to present facts or evidence concerning your property to the Harris County Appraisal District or Harris County Appraisal Review Board. Please write legibly and attach any relevant documents. You may use this form as proof of a sale of a business proof of the sale or disposition of business personal property or proof that a business did not own assets including motor vehicles aircraft and vessels which are subject to appraisal by the Harris County Appraisal District. The completed form must be delivered to the Harris official authorized to administer oaths and submitted to the address above. Part I - Owner/Business Name and Property Identification Property Owner Tax ID Number Mailing Address P. O. Box or number and street Property Description City State and ZIP 4 Tax Year s Daytime Telephone Number area code and number Agent s Name and Code if any HCAD Account Number Part II - Property Status Mark the appropriate box and provide all relevant information in the space provided* The business was closed* The business or property was sold. Date of Closure Date of Sale Purchaser Date of Move Address New Location Property including vehicles aircraft or vessels is not used for the production of income. Note Depreciable assets for purposes of federal taxation including motor vehicles aircraft vessels as well as assets in storage are considered income producing assets. SOLD Vehicle s Aircraft or Vessel s sold before January 1. Please complete the chart below Year Built VIN Number vehicle N Number aircraft or Official Number vessel License Number vehicle Serial Number aircraft or Name vessel Purchaser Name Address Date of Transaction SITUS Vehicle s Aircraft or Vessel s sitused in another county or state. Please complete the chart below Description/Make/Model Explanation Use this space to explain or clarify the status of your business or any assets owned by your business. Please continue on other side of form* Situs county or state Part III - Attestation I printed name of person making affidavit being first placed under oath by the undersigned official authorized to administer oaths under the laws of this State do solemnly swear or affirm that the information herein and attached is true and correct. Sworn and subscribed to before me this day of. seal Signature of property owner/affiant Title Printed NOTARY PUBLIC State of Texas My Commission Expires The making of a false statement in a governmental record is punishable as provided by Section 37. Please write legibly and attach any relevant documents. You may use this form as proof of a sale of a business proof of the sale or disposition of business personal property or proof that a business did not own assets including motor vehicles aircraft and vessels which are subject to appraisal by the Harris County Appraisal District. The completed form must be delivered to the Harris official authorized to administer oaths and submitted to the address above.

Affidavit of diligent search f... INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM 12.913(b), AFFIDAVIT OF DILIGENT SEARCH AND INQUIRY When should this form be used? This form is to be used with Notice of Action for Dissolution

Arizona affidavit of financial... Name Mailing Address City State Zip Code Daytime Phone Number Evening Phone Number Representing Self State Bar Number Petitioner Respondent FOR CLERK S USE ONLY SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY Case No. Petitioner/Plaintiff ATLAS No. AFFIDAVIT OF FINANCIAL INFORMATION Affidavit of Name of Person Whose Information is on this IMPORTANT INFORMATION ABOUT THIS DOCUMENT WARNING TO BOTH PARTIES This Affidavit is an important document. You must fill out this Affidavit completely and provide accurate information. You must provide copies of this Affidavit and all other required documents to the other party and to the judge. If you do not do this the court may order you to pay a fine. I have read the following document and know of my own knowledge that the facts and financial information stated below are true and correct and that any false information may constitute perjury by me. I also understand that if I fail to provide the required information or give misinformation the judge may order sanctions against me including assessment of fees for fines under Rule 31 Arizona Rules of Family Law Procedure. If you do not do this the court may order you to pay a fine. I have read the following document and know of my own knowledge that the facts and financial information stated below are true and correct and that any false information may constitute perjury by me. I also understand that if I fail to provide the required information or give misinformation the judge may order sanctions against me including assessment of fees for fines under Rule 31 Arizona Rules of Family Law Procedure. Date Signature of Person Making Affidavit INSTRUCTIONS Complete the entire Affidavit in black ink. If the spaces provided on this form are inadequate use separate sheets of paper to complete the answers and attach them to the Affidavit. Years and I attached my W-2 and 1099 forms from all sources of income. ALL RIGHTS RESERVED AFI DROSC13f-091511 Page 1 of 7 Case No. 1. I also understand that if I fail to provide the required information or give misinformation the judge may order sanctions against me including assessment of fees for fines under Rule 31 Arizona Rules of Family Law Procedure. Date Signature of Person Making Affidavit INSTRUCTIONS Complete the entire Affidavit in black ink. If the spaces provided on this form are inadequate use separate sheets of paper to complete the answers and attach them to the Affidavit. Answer every question completely You must complete every blank. If you do not know the answer to a question or are guessing please state that. If you do not do this the court may order you to pay a fine. I have read the following document and know of my own knowledge that the facts and financial information stated below are true and correct and that any false information may constitute perjury by me. I also understand that if I fail to provide the required information or give misinformation the judge may order sanctions against me including assessment of fees for fines under Rule 31 Arizona Rules of Family Law Procedure.

Ma workmans comp affidavit for... Print Form The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance

Small estate affidavit form SMALL ESTATE AFFIDAVIT For Transfer of Property When a Person has Died FORMS and INSTRUCTIONS Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED PBSE1 5280 - 102513 SELF-SERVICE CENTER This packet contains court forms and instructions to file a small estate affidavit of transfer. Check only ONE. 200 ESTATE 201 Formal Appointment of Personal Representative 202 Informal Appointment of Personal 203 Ancillary Administration 204 Affidavit of Succession to Realty 205 Trust Administration 206 Formal Probate of Will 208 Proof of Authority 210 Other 220 CONSERVATOR 221 Minor 222 Adult Incapacitated Person 230 GUARDIANSHIP 233 Adult Requiring In-Hospital Mental Health Treatment Specify 211 Single Transaction/Limited Conservatorship 212 Foreign Domicilliary PB10f-072913 Case No. the person to serve as guardian conservator or personal representative executor of the Estate of someone who died. TELEPHONE Work CERTIFICATION for State-Licensed Fiduciaries ONLY RELATIONSHIP TO THE WARD OR if an estate matter THE DECEDENT PHYSICAL DESCRIPTION RACE HEIGHT EYE COLOR HAIR COLOR By signing below I state to the Court under penalty of perjury that the contents of this document are true and correct to the best of my knowledge and belief. Petitioner or Attorney Signature NOTICE SUBMIT THIS FORM WITH NEW CASES ONLY. If there is already a Maricopa County Probate Court case number and you are filing in an existing In the Matter of the Estate of AFFIDAVIT FOR TRANSFER OF TITLE OF REAL PROPERTY an Adult a Minor deceased COUNTY OF MARICOPA ss. died on name date PLACE OF DEATH. Check one box At the time of death the person who died was living in Maricopa County in Arizona OR city and state and owned real property located in Maricopa County in Arizona. real property is ATP INTEREST OF PERSON WHO DIED IN PROPERTY. Items in BOLD are forms that you will need to file with the Court. Non-bold items are instructions or procedures. Do not copy or file those pages Order File No* Title pages PBSE1t Table of contents this page Checklist You may use this packet if. PBSE11f Affidavit for Collection of All Personal Property PB10f Probate Cover Sheet Only needed if transferring real property Affidavit for Transfer of Title to Real Property PBSE10p PROCEDURES What to Do After Completing the Affidavit s The documents you have received are copyrighted by the Superior Court of Arizona in Maricopa County. You have permission to use them for any lawful purpose. These forms shall not be used to engage in the unauthorized practice of law. The Court assumes no responsibility and accepts no liability for actions taken by users of these documents including reliance on their contents. The documents are under continual revision and are current only for the day they were received* It is strongly recommended that you verify on a regular basis that you have the most current documents. PBSE1t-071111 Page 1 of 1 A. R*S* 14-3971 FOR TRANSFER OF PROPERTY WHEN PERSON HAS DIED You may use the forms and instructions in this packet if.

Sworn affidavit form kenya IN THE MATTER OF OATHS AND STATUTORY DECLARATIONS ACT (CHAPTER 15 OF THE LAWS OF KENYA) AFFIDAVIT I ................................................................................................

Affidavit hcad form Harris County Appraisal District P. O. Box 920975 Houston, Texas 77292-0975 (713) 812-5830 Form 37A (01/05) Affidavit Account Number: Tax Year: Instructions: This affidavit is for property owners

Intent affidavit form SMALL WORKS PUBLIC WORKS CONTRACT 2 500 or less including tax STATEMENT OF INTENT TO PAY PREVAILING WAGES AND AFFIDAVIT OF WAGES PAID This form must be typed or printed in ink and completed in full or it will be returned for correction. Large bold numbers match instructions on the back of this form. Shaded areas are for the Awarding No filing fee Agency and Labor Industries L I use only. 12. 040 1. 10 Approval Name and Title of Individual Authorized to Approve This Phone Number Email Address Form on Behalf of the Awarding Agency type or print Signature of Individual Authorized to Approve This Form on Behalf of the Awarding Agency Received Department of Labor Industries Date F700-106-000 Combined Intent Affidavit Small Works 2 500 or less 09-2010 INSTRUCTIONS FOR COMPLETING THE FOR SMALL WORKS PUBLIC WORKS CONTRACTS 2 500 OR LESS INCLUDING TAX Contractors Please submit this form to the CONTRACT AWARDING AGENCY not to Labor Industries. Contractors may obtain this form from the CONTRACT AWARDING AGENCY only. Contractors must complete and return the form to the CONTRACT AWARDING AGENCY. If the agency approves the form it will send a copy of the approved form to L I within 30 days of the date the agency received the form from the contractor. 1 Contract Awarding Agency Project Name Awarding Agency Address Contract or Purchase Order Number City State ZIP 4 Indicate Total Dollar Amount of Your Contract - Include Sales Tax No Time Materials allowed County Where Work Was Performed City Where Work Was Performed Date Contract Awarded mm/dd/yy Date Work Completed mm/dd/yy 2 Number of Owner/Operators who own at least 30 of the company who performed work None 0 on this project check one box 3 Did employees perform work on this project check one box Yes No Crafts/Trades/Occupations and Apprentices For Apprentices enter the name registration number trade dates worked on project stage of progression wage and usual benefit for each apprentice. Contractor Registration Number Two 2 Three 3 If Yes - please list below Number of Workers in Each Trade Total of Hours Worked Rate of Hourly Wages Rate of Hourly Usual Fringe Benefits Contractor Address 9 Contractor Company Name Contractor Phone Number One 1 Contractor Email Address Contractor UBI Number Contractor Industrial Insurance Account Number I hereby certify that the above information is correct and that all workers I employed on this Public Works Project were paid no less than the Prevailing Wage rate s as determined by the Industrial Statistician of the Department of Labor Industries. I understand that contractors who violate are subject to fines and/or debarment and will be required to pay any back wages due workers. See RCW 39. 12. 065. Contractor Signature Date Title PLEASE NOTE In approving this form the Awarding Agency must verify that the Contractor s Registration or License is current and valid* The contract dollar amount indicated shall only be for a single payment in full on a single contract with the Awarding Agency.

Affidavit by producing broker... PART C AFFIDAVIT BY PRODUCING BROKER 1. PRODUCING BROKER INFORMATION AFFIDAVIT NO. License No. BR- Name Address City State Zip Code 2. RISK INFORMATION Name of the Insured The name of the insured must be precisely the same in this affidavit and the declarations page binder cover note or confirmation of coverage. 3. DISCLOSURE INFORMATION Yes No Did you personally provide a written Notice of Excess Line Placement Form NELP/2011 to the insured as ...

Ohio dbe annual affidavit form Annual Affidavit for DBE Certification SECTION 1 COMPANY INFORMATION 1. Legal name of business 2. Other names used by business 3. Website if have one 4. Federal tax ID 5. Company phone 8. E-mail communications 6. Other phone Yes 7. Company fax 9. County only if an Ohio company No 10. Street address of company No P. O. box City State Zip 11. That the Ohio Department of Transportation may deny certification or rescind certification and initiate action under Federal or State laws concerning false statements if during or after the certification process it finds that the undersigned has submitted false inaccurate or misleading information. implementation of the DBE eligibility standards despite the fact that said business may be certified by another entity. 7. That the firm meets the Small Business Administration SBA criteria for being a small business concern and its average annual gross receipts as defined by the SBA rules over the firm s previous three fiscal years do not exceed the work type limit. I recognize and accept the seven 7 statements above governing the consideration of this affidavit and the maintenance of my business certified status. DISADVANTAGED BUSINESS ENTERPRISE PROGRAM TITLE 49 OF THE CODE OF FEDERAL REGULATIONS PART 26 ANNUAL AFFIDAVIT The purpose of the annual affidavit is to identify owner or company changes that may effect DBE certification* This information is required to maintain or renew DBE certification* Contents Section 1 Company Information Section 2 Annual Affidavit Questions Section 4 Certification Information Section 5 Supporting Documents Checklist Affidavit of Certification To complete this document 1. Enter the Company Information in section 1. 2. Check the Yes/No boxes for section 2 Annual Affidavit Questions. Where required provide details. 3. Provide supporting documents as required in section 3 Supporting Documents Checklist. 4. Sign the Affidavit in the back of the document and have it notarized* 5. Submit the entire document with supporting documents to your certifying agent by the due date. Annual Affidavit for DBE Certification SECTION 1 COMPANY INFORMATION 1. Legal name of business 2. Other names used by business 3. Website if have one 4. Federal tax ID 5. Company phone 8. E-mail communications 6. Other phone Yes 7. Company fax 9. County only if an Ohio company No 10. Street address of company No P. O. box City State Zip 11. Mailing address of company if different Indicates required field for new applicants or new records. Section 1 Company Information Page 1 SECTION 2 ANNUAL AFFIDAVIT QUESTIONS 1. Has the ownership management or control of the company changed in any way in the past year If Yes please use section 3 the Company Owners and Representatives form to indicate modifications. 2. Have there been any investments or contributions of capital in the company over the past year If Yes please provide details under the Asset Transfers heading in section 4C. 3. Has the company or any of its owners board members officers or management been denied certification denied re-certification or been decertified as a DBE in the past year storage space in the past year If Yes please list those things that have been acquired or liquidated in section 4C.

Affidavit of support sample fo... Thank you for your interest in pursuing a degree at Wilmington University that offers both undergraduate and graduate programs at Wilmington University in a wide range of instructional areas. For

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