SUBMIT TESTIMONY

In order for us to share an individual’s written testimonials, all stories must be submitted by completing this legal declaration of fact. This is needed so we can show record that we have done our due diligence to ensure that everything we share on our site and social media is truthful and factual. While we will honor any request to be anonymous when sharing your story, your actual name and the name of the program must be included in this form.

DECLARATION UNDER PENALTY OF PERJURY

PURSUANT TO 28 USCA 1746

[SPECIAL NOTE: STATUTE DOES NOT REQUIRE NOTARY]

I give Breaking Code Silence permission to use this statement on their website and all social media platforms. I declare under penalty of perjury that the foregoing written statement is true and reported from my own first-hand experience.

Name of Declarant

Failure to provide a name might result in the rejection of the submission.

Do you wish to have your story published anonymously? *

For those who choose not to remain anonymous, we will only publish your story with your first name.

Email of Declarant *

Failure to provide a real email address may result in a rejection of the submission

(Optional) Upload a picture of your time in the program .jpeg, .jpg, and .png file formats only accepted

Choose File