STATE OF MISSOURI )
COUNTY OF _______________________ )
COMES NOW Jane Doe, of lawful age, being duly sworn, upon her oath, acknowledges
that she has read the foregoing and that the statements contained therein are true and correct to
her best knowledge and belief.
Jane Doe, Petitioner
Subscribed and sworn to before me, a Notary Public, at my office in the County and State
aforesaid, on this ______ day of _________________________, 2010.
My Commission Expires: