I, (first and last name)_____________________________, declare and state as follows:

My name is (name)_________________________________. My address is (address: number, street and city)_______________________________, ______________, California, zip code ______________.

I have personal knowledge of all facts contained in this declaration, and if called upon to testify, could do so competently.

The following took place on or about (date): ______________, 200___

(Body of the Declaration where personal knowledge details are explained in chronological order)

I declare under penalty of perjury and the laws of the State of California that the above is true and correct.

Dated: _________________, 2004

_______________________________
(Signature)

Area code and phone number (_______) ___________________________