An unsworn declaration under this part must be in substantially the following form:

I declare under penalty of perjury under the law of Tennessee 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)