This document records a statement for a project located at an unspecified location. The statement is provided and written by an individual who acknowledges that the information is true to the best of their recollection. The individual provides their name, signature, position and date at the end of the statement.

1. STATEMENT
PROJECT:
LOCATION: DATE:
I (name)_____________________________________would like provide my statement as follows on.
I hereby acknowledge that the above statement are true to the best of my recollection, and that these
are my very own written down by m myself s others _________Name and Signature________
Name : ____________________________ Signature: ______________________
Position: _________________________________________Date:_________________