[Today`s Date] [Your Name] [Current Street Mailing Address] [Current

[Today’s Date]
[Your Name]
[Current Street Mailing Address]
[Current Address City, State, Zip]
[Insurance Company Name]
[Insurance Company Street Mailing Address]
[Insurance Company Mailing City, State, Zip]
Re: [Your Sandy insurance claim #]
Date of Loss: [the Date of Loss for your Sandy insurance claim]
Address of Loss: ________________________
Insurance Policy #:_______________________
Sworn Statement of [name of person (witness or neighbor)who provides this
[Here, the witness signing the statement will write a chronological account of the events that
she or he saw. The person should include as much detail as possible for names, dates, times, and
locations. This statement should be written in the witness’ own words. If the witness does not know
something for sure, then that should be indicated. For example, the statement might read:
“I live at 123 Main Street, Seatown, NJ. My next door neighbor is John Doe, who lives at 125
Main Street, Seatown, NJ. My house is elevated on 10’ pilings, so my house looks down over John Doe’s
house. On October 29, 2012, the wind and rain from Sandy were in my town. Because my house is
elevated and the town was not evacuated, I felt safe staying in my house during Sandy and I was in my
house for the entire day on October 29. I went upstairs to my attic in the afternoon to look out the
window – I do not recall the exact time. I looked at John Doe’s house and saw several roof shingles get
blown away when a gust of wind hit the roof. I heard the sound of the shingles being blown off by the
wind. I do not know the exact number of how many shingles blew off.”]
[The witness’ sworn statement must include the following language:]
I certify that the foregoing statements by me are true. I am aware that if any of the foregoing
statements made by me are willfully false, I am subject to punishment.
[Witness full name]
[Witness Signature]
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