STATE OF _____________
COUNTY OF ____________
I swear or affirm under penalty of perjury that I do not now and I have not at any time, either as an adult or as a juvenile:
Any conduct, matter, or thing (irrespective of formal name thereof) constituting or involving (whether under criminal or civil law of any jurisdiction):
Except the following (list all incidents, location, description, and date) (if none, write NONE)
Signed ________________________
Date _______________.
Subscribed and sworn to (or affirmed) before me this ________ day of ________________,____________.
Signature of notarial officer ____________________________________.
(seal, if any, of notarial officer)
My commission expires: ____________
Tex. Hum. Res. Code § 42.059