Affidavit Certifying Business Records
THE STATE OF _____________ )
) ss
COUNTY OF ________________ )
AFFIDAVIT
Before me, the undersigned authority, personally appeared __________________, who, being by me duly sworn, deposed as follows:
My name is _____________________, I am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated:
I am the custodian of the records of __________________.
Attached hereto are _______ pages of records from __________________. These ____ pages of records are kept by ___________________ in the regular course of business, and it was the regular course of business of ______________________ for an employee or representative of _____________________ with knowledge of the act, event, condition, opinion, or diagnosis recorded to make the record or to transmit information thereof to be included in such record; and the record was made at or near the time of the act, event, condition, opinion or diagnosis. The records attached hereto are the original or exact duplicates of the original.

_____________________________
Affiant

In witness whereof I have hereunto subscribed my name and affixed by official seal this _____ day of __________________, 20___.

_____________________________
(Signed)

(Seal)