Statutory Declaration of Receipt of Funds

STATUTORY DECLARATION OF RECEIPT OF FUNDS

I, ______, of ______, in the Province of Ontario, SOLEMNLY DECLARE that:

1. I have received from ______ the sum of ______, paid by ______, on ______.

2. The payment was made for: ______.

3. This payment is ______.

4. I acknowledge receipt of the funds, and I make this declaration for the following purpose: ______.

I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.

DECLARED before me at the ______________________ of ______________________, in the Province of Ontario, this ______ day of ______________, 20______.

_______________________________ _______________________________

A Commissioner for taking Affidavits Signature of Declarant