Indiana Code Title 34. Civil Law and Procedure § 34-59-1-11

Sec. 11. An unsworn declaration under this chapter must be in substantially the following form:

I declare and affirm under penalty of perjury under the laws of Indiana that the foregoing is true and correct, and that I am physically located outside the geographic boundaries of the United States, Puerto Rico, the United States Virgin Islands, and any territory or insular possession subject to the jurisdiction of the United States.

Executed on the__________day of__________, _________, at

(date) (month) (year)

___________________________, __________.

(city or other location, and state) (country)

________________________

(printed name)

________________________

(signature)