Form R-4 - Information To Be Furnished By Promoters, Directors, Officers And Partners Of, Issuers Or Investment Advisers - 2013 Page 5

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Form R-4
11/12
Page 4
EXECUTION
I, ________________________________________________ do solemnly swear that the
foregoing answers and statements, together with those in all Exhibits attached hereto, have been
knowingly made by me and that the same are true and correct, and that I have not omitted to state
any material fact bearing upon such matters.
Given under my hand this __________day of ___________ ______
(year)
____________________________
Signature of Principal
Affidavit number ___________
Subscribed and sworn before me by __________________________ of legal age,
________________________________________,
and
resident
of
__________________
(married or single)
personally known to me this _______________day of _________________________ of _____.
(year).
At ___________________________________
____________________________
Notary Public
Instructions:
The principal executing this form is required under applicable law to keep the information up to
date.

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