IN THE CIRCUIT COURT OF __________ COUNTY, _______________STATE
VS. CIVIL ACTION NO.:
_______________________ CV _________________
AFFIDAVIT OF EXPERT NAME
STATE OF ______________
COUNTY OF ______________
Before me, the undersigned Notary Public, personally appeared ___________________ [EXPERT’S NAME], who after being first duly sworn, did depose and say:
My name is ____________________, and I have personal knowledge of the matters contained in this Affidavit. I am a licensed professional counselor and a practicing Psychometrist. Psychometry is the profession/field of interpreting numbers associated with educational testing; specifically, to determine one’s cognitive and academic abilities. Cognitive means a person’s innate intelligence ability, and academic means a person’s acquired knowledge. I received a M.Ed. Degree in Special Education from the University of _________________ in ______________________, and a B.S. Degree in Early Childhood Education from the University of ____________________ in ________________________. I am currently President of __________________. In that capacity, I perform diagnostic testing, and provide services as a professional counselor of children and adults who have learning disabilities and/or Attention Deficit Hyperactivity Disorder. I am qualified to perform tests on individuals to determine their reading and comprehension abilities, through my education, degrees, passing the test required by the Board of Examiners in Counseling for the State of ___________, and my experience. (A copy of my curriculum vitae is attached to this Affidavit as Exhibit 1).
The tests I use are accepted and routinely used in the education, psychology, counseling, and psychometry professions to determine an individual’s reading ability level and reading comprehension ability level.
I performed the (test(s) on _____________________ [individual’s name] on __________________ [date,] at ______________________________ [location of testing] in ______________ [city], _____________ [state], to test his/her reading ability and reading comprehension ability. The test measures ___________________________________________________[describe test/tests] . Mr./Mrs.________________________ tested at the ________ level for reading ability and the ______ level for reading comprehension on the Test; at the ______ level for (reading/comprehension) on the Test; and at the ______ level for (reading/comprehension) on the . With scores at these levels, Mr./Mrs. would be considered (functionally illiterate/illiterate).
FURTHER, AFFIANT SAYETH NOT.
STATE OF __________________
COUNTY OF ________________
I, the undersigned Notary Public, in and for said State and County, hereby certify that _________________________, whose name is signed to the foregoing Affidavit, and who is known to me, acknowledged before me on this day that, being informed of the contents of said Affidavit, she executed same voluntarily on the day the same bears date.
Given under my hand and seal this _____ day of _____________, 20____ .
My Commission Expires:_____________________
State Specific Affidavit Forms
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