IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
CIVIL DIVISION
________________________________ ) CIVIL DIVISION
)
________________________________ ) LT _____________________
Plaintiff/Landlord )
vs. )
________________________________ )
)
________________________________ )
Defendant(s)/Tenant(s) )
AFFIDAVIT OF CENTER OF DISEASE CONTROL AND PREVENTION DECLARATION
Please check one and sign where applicable:
I, ______________________________, do hereby affirm that I, the landlord, for the property at issue
have NOT received a CDC Declaration form from the tenant for the property at issue.
______________________________ ______________
Signature of Landlord Date
I, ______________________________, do hereby affirm that I, the landlord for the property at issue
have received a CDC Declaration form from the tenant for the property at issue.
______________________________ ______________
Signature of Landlord Date
I understand that false statements herein are subject to the Penalties of 18 P. C. S. §4904 related to
unsworn falsification to authorities.
__________________________ ______________________
Signature of Landlord Date
