Affidavit of Publication of Certificate : Please fill out the following form. Please print your completed form if you would to have a copy for your records.




STATE OF


COUNTY OF


(Name of the person giving statement), affiant, of (ADDRESS), City of (CITY), County of (COUNTY), State of (STATE), being duly sworn on oath, deposes and says:


1. Affiant is or was the (Person's title) of (News Paper) a daily newspaper of general circulation, printed, published, and circulated in the City of (CITY), County of (COUNTY), State of (STATE).


2. The original or renewal (Fictitious or Assumed Name) name certificate, a true copy of which is attached hereto and marked as Exhibit A, was published in said newspaper once a (Day, week or month) for 20 successive (Days, weeks or months), on the following dates:


Dates of publications


and the publication was made in the newspaper proper and not in a supplement.


Dated :


On _______________ before me _________________ personally appeared ______________________ personally known to me (orproved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.


WITNESS my hand and official seal.


Signature :


Affiant : Known / Unknown


ID Produced :


Seal :





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