FORM AR-1
(08/10)
Business Records Affidavit
This affidavit should be executed before a Notary Public or other official authorized to administer oaths and attached
to the applicable business records. Please print or type.
Before me, the undersigned authority, personally appeared ______________________________________, who
being by me duly sworn, deposed as follows:
My name is __________________________________________, I am of sound mind, capable of making this affidavit,
and personally acquainted with the facts herein stated:
I am the custodian of the records of ___________________________________________. Attached hereto are
_________________________pages of records from __________________________________________. These
said _______________________ pages of records are kept by __________________________________________
in the regular course of business, and it was the regular practice of said entity for an employee or representative with
knowledge of the act, event, condition, opinion, or diagnosis, recorded to make the record or to transmit information
thereof to be included in such record; and the record was made at or near the time or reasonably soon thereafter.
The records attached hereto are the original or exact duplicates of the original.
Affiant's Signature
SWORN TO AND SUBSCRIBED before me on the _____ day of __________________________, _________.
(seal)
Notary Public, State of Texas
Notary's Printed Name
My commission expires
Tax Year HCAD Account Number
(NAME OF BUSINESS)
(NAME OF BUSINESS)
(NAME OF BUSINESS)
