DECLARACIÓN JURADA Formulada por D./Dª. ____________________________________________________ con D.N.I. nº _________________________ mayor de edad y con domicilio en ______ _____________________________________________de______________________

DECLARA BAJO JURAMENTO Que:_________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Y para que conste ante el Organismo Administrativo o Judicial competente,

firmo la presente en Badajoz, a __________ de ______________________ de 2.01 2

FIRMA