Form of unsworn declaration. An unsworn declaration under ORS 194.800 to 194.835 must be in substantially the following form

______________________________________________________________________________

I declare under penalty of perjury under the law of Oregon that the foregoing is true and correct, and that I am physically located outside the geographic boundaries of the United States, Puerto Rico, the United States Virgin Islands and any territory or insular possession subject to the jurisdiction of the United States.

Executed on the ___ day of ______, _____, at ____________, (date) (month) (year) (city or other location, and state)

____________

(country)

____________

(printed name)

____________

(signature)

______________________________________________________________________________ [2013 c.218 §6]

Note: See note under 194.800.