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FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

[plfName]	)	Case No (LT)
Petitioner	)	[caseNo]
)
v.	)
)
[defName]	)
Respondent	)

PETITIONER’S AFFIDAVIT

The affiant, [plfName], swears or affirms as follows:

Background

I am over the age of eighteen (18).

I am a plaintiff in the above-captioned case.

This affidavit is made in good faith.

Familiarity

I have read DOAH’s Uniform Rules of Procedure, Florida’s Administrative Procedures Act (§120 FS), the Florida Rules of Civil Procedure, and other pertinent regulations from the Florida Administrative Code.

The information in this affidavit is based on my own personal knowledge.

Facts

[pertinentFact001].

[pertinentFact002].

[pertinentFact003].

[pertinentFact004].

[pertinentFact005].

[pertinentFact006].

Verification Under Oath Pursuant to §92.525(1)(c)

Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true to the best of my knowledge and belief.

STATE OF FLORIDA COUNTY OF DUVAL	[D]/[M]/[YYYY]
[plfName], Petitioner/Affiant

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