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FLORIDA NOTARIAL CERTIFICATE
(OATH OR AFFIRMATION FOR INDIVIDUAL WITH DISABILITY)
1. _______________________________ _______________________________
Printed Name and Address of Witness Signature of Witness
2. _______________________________ _______________________________
Printed Name and Address of Witness Signature of Witness
_______________________________
Signature Affixed by Notary, Pursuant
to § 117.05(14), Florida Statutes
STATE OF FLORIDA
COUNTY OF _________________
Sworn to (or affirmed) and subscribed before me this ___ day of _________________, 20___,
by _________________ (Name of Person with Disability), and subscribed by (Name of
Designated Person) in the presence of _______________________________ (Names of
Witnesses) at the direction of _________________ (Name of Person with Disability).
(Seal)
_______________________________
Signature of Notary Public
_______________________________
Print, Type or Stamp Name of Notary
Personally Known: ____
OR Produced Identification: ____
Type of Identification Produced: _________________
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