AFFIDAVIT OF BROADCAST
State of ______________
County of ______________
I _____________________, being duly sworn, depose and say that I am the owner, manager, assistant manager or program director of station _________________________, a radio (television) station broadcasting from _______________, and state that the notice (or summary or description of the notice) described as ________________________ was broadcast on the following days:
Date: Time:
Date: ______________________ Time: ______________________
Date: ______________________ Time: ______________________
Date: ______________________ Time: ______________________
Date: ______________________ Time: ______________________
________________________________
Signature
Subscribed and sworn before me ____________ 20 ____.
________________________________
Notary Public/Justice of the Peace
My commission expires:
____________________
State Specific Affidavit Forms
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