Sworn Statement
I, ________________________________________, do hereby swear and confirm the following:
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Tenant Signature _______________________________________ Date ___________________
Tenant Street Address ___________________________________________________________
Tenant Phone Number ___________________________________________________________
Signature of Witness ____________________________________ Date ___________________
WARNING: SECTION 1001 OF TITLE 18 OF THE U.S. CODE MAKES IT A CRIMINAL OFFENSE TO MAKE WILLFUL FALSE STATEMENTS OR MISREPRESENTATIONS TO ANY DEPARTMENT OR AGENCY OF THE U.S. AS TO ANY MATTER WITHIN ITS JURISDICTION.
ALTERNATIVE FORMATS OF THIS DOCUMENT ARE AVAILABLE UPON REQUEST.
575 Union Blvd Suite 100, Lakewood, Colorado 80228 ● Phone 303-987-7580 ● TTY 711 ● www.mwhs.org
