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Can someone answer this question about an Affidavit of Eligibility

I won a CBS Sportsline Fantasy League.

I'm trying to fill out the Affidavit

At the end it says....

"Sworn to before me this 22nd day of October 2006,

------------------(print name)[ ]personally known to me or [ ] who prduced the following identification:


--------------------------------------------------------------------------------


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Notary Public
Commissioner expires:



I have no clue what to type in the blanks. Can anyone help me out here?
Joel C

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