Form 16-C Sample Business Records Certification [Authorized under V.I. Rules of Evidence 803(6)-(7) and 902(11).] SUPERIOR OF THE VIRGIN ISLANDS DIVISION OF [Insert Division] ) ) ) CASE NO. [Insert Plaintiff, No.] v. ) ) ) DECLARATION Defendants. ) BUSINESS RECORDS CERTIFICATION I, [print in my capacity as name] [a custodian of the records; or other stated position making the of signer a qualified witness on behalf thebusiness/office] [name do hereby make this Declaration under penalties of perjury, of business/office] and state: I am over the age of 18 years, of sound mind, and competent to make this Declaration. I have personal knowledge of the facts herein stated because of my employment position and experience. Attached to this Declaration are pages of records from our business/office, which are exact duplicates of the records in ourfiles. The records annexed to this Declaration: were made at or near in time to the events and informationrecorded; were created by (or from information transmitted directly from) persons who had knowledge of the events/informationrecorded; were made in the course of our regularly conducted business activity; and were made and kept as a necessary part and regular practice of ourbusiness. [Include 5, 6 7 ¶¶ and/or for medical records and medical billing records only.] The attached records relate to medical treatment and medical billing for the identified patient, and: Trial records are exact duplicates of the records in ourfiles. The amount of charges incurred for the services provided was $ . The total amount paid by the patient (or the patient’s insurer) was $ .
Form 16-C Sample Business Records Certification [Authorized under V.I. Rules of Evidence 803(6)-(7) and 902(11).] SUPERIOR OF THE VIRGIN ISLANDS DIVISION OF [Insert Division] ) ) Plaintiff, ) CASE NO. [Insert No.] v. ) ) Defendants. ) DECLARATION ) BUSINESS RECORDS CERTIFICATION I, [print name] in my capacity as [a custodian of the records; or other stated position making the signer a qualified witness on behalf thebusiness/office] of [name of business/office] do hereby make this Declaration under penalties of perjury, and state: I am over the age of 18 years, of sound mind, and competent to make this Declaration. I have personal knowledge of the facts herein stated because of my employment position and experience. Attached to this Declaration are pages of records from our business/office, which are exact duplicates of the records in ourfiles. The records annexed to this Declaration: were made at or near in time to the events and informationrecorded; were created by (or from information transmitted directly from) persons who had knowledge of the events/informationrecorded; were made in the course of our regularly conducted business activity; and were made and kept as a necessary part and regular practice of ourbusiness. [Include ¶¶ 5, 6 and/or 7 for medical records and medical billing records only.] The attached records relate to medical treatment and medical billing for the identified patient, and: records are exact duplicates of the records in ourfiles. The amount of charges incurred for the services provided was $ . The total amount paid by the patient (or the patient’s insurer) was $ . Trial