Jurat of Affidavit Taken by Commissioned Officer of Armed

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					            Jurat of affidavit taken by commissioned officer of Armed Forces—California.

Subscribed and sworn to before me on this    day of       [date].


                                                                                                 (Signature)

                                                                                           (Serial Number)

                                                                                                      (Grade)

                                                                     (Branch of service: Army, Navy, etc.)

                                                                            (Permanent mailing address)




                                                                                             electronic form 2005
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