Certification of Records Custodian

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF VIRGINIA

NAME :

Plaintiff, :

v. : CASE NO.: 000000000000

NAME :

Defendant. :

:

:

:

CERTIFICATION OF RECORDS CUSTODIAN

I am the authorized Custodian of Records for (NAME OF MEDICAL PROVIDER) and I

have authority to certify the attached records of (PATIENT’S NAME).

I HEREBY CERTIFY that:

These records were produced in my presence or at my direction. These records were

made at, or near the time of the occurrence or the matters set forth by (or from information

transmitted by) a person with knowledge of those matters, were made and kept in the regular

course of regularly conducted business activity, and were made and kept by the regularly

conducted business activity as a regular practice.

I declare and affirm under the penalty of perjury that the aforementioned facts are true

and accurate to the best of my knowledge, information and belief.

Signature:_______________________

Print:___________________________

Title:____________________________