Appendix A to Part 389

I, ______________, pursuant to the provisions of 49 CFR part 389, section 389.9, state as follows: (1) I am [insert official's name, title] and I am authorized by [insert name of entity] to execute this Affidavit on its behalf; (2) I certify that the information contained in the document(s) attached to this Affidavit is submitted voluntarily, with the claim that the information is entitled to confidential treatment under 5 U.S.C. 552(b)(4); (3) I certify that the information contained in the documents attached to this Affidavit is of a type not customarily disclosed to the general public by [insert name of entity]; (4) I certify that, to the best of my knowledge, information and belief, the information contained in the documents attached to this Affidavit, for which confidential treatment is claimed, has never been released to the general public or been made available to any unauthorized person outside [insert name of entity]; (5) I certify that this information satisfies the substantive criteria set forth in the notice published in the Federal Register on ______[insert date of rule-specific publication in month/day/year format] under FMCSA Docket Number [insert docket number]. (6) I make no representations beyond those made in this Affidavit, and, in particular, I make no representations as to whether this information may become available outside [insert name of entity] due to unauthorized or inadvertent disclosure; and (7) I certify under penalties of perjury that the foregoing statements are true and correct. Executed on this __day of ___, ____. __________________(signature of official)