AFFIDAVIT OF AMERICAN MANUFACTURE OF A^
COPYRIGHT BOOK.
Fill in the required statements to accord with the facts concerning the book named, and draw pen through such statements as are not intended to be made.
State of
County of_
Impression seal
here -r
•*>
( being duly sworn, depose 1 ' ( do solemnly affirm ) ■' "
(i) That I am the person claiming copyright in the book named herein.
(2) That I am the duly authorized agent or representative residing in the United States of the claimant of copyright in the book named herein.
(3) That I am the printer of the book named herein.
I further depose and say that, in so far as required by the Act of March 4, 1909,
the BOOK ENTITLED
of which two copies have been deposited, has been printed by_
_at_
( type )
from I plates made in the U. S. from type | ^et within the limits of the United
States by at ;
that the printing of the text of the said book was completed on ,
19 ; that the said book was published on , 19 ;
that the binding of the said book has been performed within the limits of the
United States by at
(Signature)-
, ( sworn to ) , , , . , , Subscribed and -j affirmed \ ^^^°^^ '"^ *'* °^y °^ ' '9-
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