50 Ill. Adm. Code 1705.EXHIBIT A
A Certificate of Compliance
Section 1705
Section 1705.EXHIBIT A Certificate
of Compliance
STATE OF
)
)
SS
COUNTY OF
)
(Official's name)
, being first duly sworn,
deposes and says that:
1. He is
the
(Official title)
of the
(Name of fraternal benefit
society)
,
a fraternal benefit society
formed under the laws of the State of
;
2. He is the
duly appointed official custodian of the Articles of Incorporation or
Association, Constitution, By-laws, Rules and Regulations of said Society;
and
3. The
certificate(s) rider(s) or endorsement(s) hereto and filed for approval
herewith are in full compliance with the provisions and requirements of those
Articles of Incorporation or Association, Constitution, By-laws, Rules and
Regulations.
(Official
Title)
Subscribed and sworn to
before me this
day of
,
19
.
Notary
Public
My Commission expires
,
19
.