Mariposa — Affirmation Form

Source: https://www.mariposa.courts.ca.gov/system/files/affirmation-form_1.pdf

Superior Court of California County of Mariposa 5088 Bullion Street Post Office Box 316 Mariposa, CA 95338

CLAIM AFFIRMATION FORM

The undersigned claimant certifies that, under penalty of perjury, the claimant has read the claim and knows the contents thereof and the claimant is the owner of the said claim and the person entitled to receive the money set forth in said claim.

The claimant agrees to indemnify and hold harmless the state, the courts and their agents, officers, and employees from any loss resulting from the payment of said claim(s).

CURRENT INFORMATION AND SIGNATURE MUST BE PROVIDED FOR EACH CLAIMANT OR YOUR CLAIM WILL NOT BE PROCESSED.

Claimant’s Information: LAST NAME OR BUSINESS NAME: FIRST NAME: MIDDLE INITIAL: SSN OR FEDERAL TAX ID: CURRENT MAILING ADDRESS:

DAYTIME PHONE: CLAIMANT OR AUTHORIZED AGENT SIGNATURE:

YOUR SIGNATURE MUST BE NOTARIZED IF THE CLAIM AMOUNT IS $1,000.00 OR GREATER.

For claims filed for a business, the authorized owner’s signature is required. For claims filed for an estate or trust, the signature of the executor, administrator, or attorney is required.

State of California ) ) County of _____________________________ )

Subscribed and sworn to (or affirmed) before me on this _________ day of ______________________, 2022, by ______________________________________, proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.

Signature ______________________________________ (Seal) Local form for Mandatory Use Mariposa Super Court MISC-006 (04/29/22)