No. .............

John Doe (Name of Plain- tiff) v

Roe John Defendant) (Name of 其 IN THE . . . . . . . . . . . . . . COURT OF . . . . . . . . . . . . . . COUNTY, Arkansas AFFIDAVIT 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 course of business of . . . . . . . . . . . . . . for an employee or representative of . . . . . . . . . . . . . ., 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

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Affiant SWORN TO AND SUBSCRIBED before me on the . . . . . . . . . . . . . . day of . . . . . . . . . . . . . ., 19. . . . . .

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Notary Public, State of Arkansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Notary’s printed name