35 Ill. Adm. Code 811.APPENDIX A
A Financial Assurance Forms
Section 811.APPENDIX AÂ Â Financial Assurance Forms
Section 811.ILLUSTRATION BÂ Â Certificate of
Acknowledgment
CERTIFICATE OF
ACKNOWLEDGMENT
State of
)
) SS
County of
)
On this
day of
,
before me personally came
(operator) to me known, who,
being by me duly sworn, did depose
and say that
she/he resides at
(address), that
she/he is
(title) of
(corporation), the corporation
described in and
which executed the above
instrument; that she/he knows the seal of said corporation; that the seal
affixed to such instrument is such corporate seal; that it was so affixed by
order of the Board of Directors of said corporation, and that she/he signed
her/his name thereto by like order.
Notary Public
My Commission Expires