Broadcast Affidavit

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

—-For State Specific Affidavit Forms you can download in Word Format go to

http://www.uslegalforms.com/affidavits/


Inside Broadcast Affidavit