2011 Utah Code
Title 78B Judicial Code
Chapter 18 Utah Uniform Unsworn Foreign Declarations Act
Section 106 Form of unsworn declaration.

78B-18-106. Form of unsworn declaration.
An unsworn declaration under this chapter must be in substantially the following form:
I declare under penalty of perjury under the law of Utah 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)