I, ____________________ (Printed name), do hereby certify that I am the individual to whom the requested record pertains or that I am within the class of persons authorized to act on his behalf in accordance with 15 CFR, Part 80 .
(Signature) _______________________________
(Date)____________________
In the County of _______________________________
State of _______________________________
On this ______ day of ________, 19____, ____________________ (Name of individual) who is personally known to me, did appear before me and sign the above certificate.
(Signature) _______________________________
(Date)____________________
(S) My commission expires_______________________________
15 C.F.R. §80.1
Approved by the Office of Management and Budget under control number 0607-0117