FILL-IN FORM

DECLARATION AND VERIFICATION OF

INTERPRETATION
Pursuant to Government Code Section 27293
I, ___________________________, declare that I am an interpreter. I can interpret and translate
from the __________________________ language to the English language.

I further declare that I have translated the attached document from the ______________________
language to the ENGLISH language. I declare to the best of my abilities and belief, that this is a
true and correct translation of the ______________________________________ language text of
______________________________________________.
(Insert title of document)

Specific Description of the Document

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
I declare under penalty of perjury under the laws of the State of California that the foregoing is true
and correct.

Date

Print Name of Interpreter

Place

Signature

New 02/07/2006