State of Illinois
Certificate of Signature
Under the Uniform Facsimile Signature of Public Officials Act
30 ILCS 320/2
Secretary of State Index Department
111 E. Monroe
Springfield, IL 62756
217-782-7017
www.cyberdriveillinois.com
Return completed form to: Secretary of State, Index Department, 111 E. Monroe, Springfield, IL 62756 • 217-782-7017
I,
_________________________________________________________________________________________________, certify that
I am an Authorized Official of _____________________________________________________________________________________
______________________________________________________________________________________________________________
within the meaning of the provisions of Section 1(c) of the Uniform Facsimile Signature of Public Officials Act and that my signature
is required or permitted on a public security or instrument of payment as defined in said Act. That I am filing my signature with
the Secretary of State, certified under oath, so as to permit the use of a facsimile thereof upon a public security or instrument of pay-
ment requiring or permitting my signature as provided under the Uniform Facsimile Signature of Public Officials Act.
I, ____________________________________________________________________________________________, certify under oath,
that the following is my manual signature:
________________________________________________________________________
Subscribed and sworn to before me this ____________________ day of ___________________________, A.D., __________________
________________________________________________________________________
Notary Public
Printed by authority of the State of Illinois. December 2009 — 50 — I 37.6
