STATE OF NEW YORK

COUNTY OF _____________________ss.:

 

______________________________________________, being duly sworn, deposes and says t hat he/she is the local educational agency liaison for homeless children and youth for the _____________________________________________ School District; that on the ____day of ______________________________, 20____ he/she accepted service of the annexed ___________________________ on behalf of _______________________________________.

 

______________________________
(Signature)

 

Subscribed and sworn to before me this ____ day of ________ 20 ______

 

______________________________
(Signature of notary public)