Form Rp-1126 - Declaration Of Interest (Page 2 of 2) in pdf

Form Rp-1126 - Declaration Of Interest Page 2

Page 2

RP-1126 (1/98)

Section Five. Authorization.

I understand that this Declaration of Interest shall expire on the last day of the tenth calendar

year commencing hereafter, unless extended or canceled. I further understand that it is the

responsibility of the party identified in Section Two of this Declaration, to amend or cancel this

Declaration of Interest upon the transfer or termination of the interest described above, or upon a

change of address of such party.

Dated: ___________________

______________________________________

(Type or print name of party identified in

Section Two, or authorized representative)

State of New York

)

) ss

County of ________________)

I, ___________________________________________, being duly sworn, say that I am the

__________________________________ (state relationship to party identified in Section Two), and

that the statements contained in this Declaration of Interest are true, correct and complete.

______________________________________

(Signature of party identified in Section Two, or

authorized representative)

Sworn before me this _________

day of _____________, _______ .

__________________________

Notary Public

Form Rp-1126 - Declaration Of Interest Page 2