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                                                                                                                     (Rev. 6)


                                                    NOTICE
                                         OFFENDER NOTARY PUBLIC SERVICE

        Under both Federal law (28 U.S.C § 1746) and State law (V.T.C.A. Civil Practice & Remedies
        Code, § 132.00 1-132.003), offenders incarcerated in Texas may use an unsworn declaration under
        penalty of perjury in place of a written declaration, verification, certification, oath, or affidavit
        sworn before a Notary Public.

            In a request for Notary Public service, each offender must explain why an Unsworn Declaration is
, ·-·- -. _jg~pJ.fi.c;i~ntb.e_fgr~,Notary Public. s~wi_ce .will b_e,provided. ····'----'···· __ _ .· .· . . .... _·_ .· .. . ...

        ******************************************************************************
                       An example of an unsworn declaration pursuant to State law is as follows:


        "My name is     ll1'-AQU l?£,Ma'{U€ ~\~~                                   my date ofbiJth is     oc:-q~ 7~
                               (First)         (Middle)            (Last)

        and my inmate identifying number, is            \~"31q'-\.'3                   . I am presently incarcerated in


         n- .. ,\'c          (Cor~~s unit name)                                                 (City}
        _co=...:."-~=---'"'-,-----\"-""
                                     -t:i"-,___f\--=--~=-----~-L~f>
                                                                 ....Su.•.~--)l"-0=----,--·   I declare under penalty of
          (County)                        (State)               (Zip Code)

        perjury that the foregoing is true and correct.

        Executed on the     7<\       day of   UClV'UClf\(= , 20 \'5'. ~OJ W~b, t.ti'-
                                                                                          (Offender Signature)
        -~***************************************************************************
                       n example of an unsworn declaration pursuant to Federal law is as




        and correct.

                            _ _ _ day of._ _ _ _ _ _ , 20_.


         . ****************************************************************************

                                                    NOTICE
                                          NOTARY PUBLIC SERVICE DENIAL
SUB.JECT: State briefly the problem on which you desire assistance.




Name:      (DMQk{ \(lj{WR{                                             No:   lg3/C(Q3         Unit:   lE(fOaJ
              BU- 4 2
Living Quarters: ')                                                    War'< Msignment:   ME"Q-~ 5        .
DISPOSITION: (Inmate w;JI not w,;te ;nth;, 'pace)                     d D {)
                       ~t        VMill (039G                                 ~~·~( n
                       y                                   .          \DVvll
-trl-60 (Rev. 11-90)
