Form Rp-1126 - Declaration Of Interest Page 2
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2RP-1126 (1/98)
Page 2
Section Five. Authorization.
I, _____________________________________, (type or print name) 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: _____________________________
___________________________________
Signature
Clear Form
State of New York
)
) ss
County of __________________ )
I, ____________________________________________ , (type or print name) 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
Sworn before me this ____________ day of ________________________, _______.
___________________________________
Notary Public
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