Fill and Sign the Canada Mortgage Loan Agreement Form

GPO USE ONLY Date Contractor Code U.S. GOVERNMENT PUBLISHING OFFICE Evaluation Sample Certificate A. SAMPLE PURPOSE. I understand that the accompanying printing/binding sample(s) submitted to the Government Publishing Office will be inspected against the Quality Assurance Through Attributes Program (QATAP), for the purpose of assisting in indicating the quality capability of the production plant of the firm identified below. B. SAMPLE PRODUCTION. I hereby certify that with the exception of any information described in this certificate, the accompanying samples were produced in the following plant by the following firm, and completed during the 6 months preceding their submission: Firm Name Plant Address C. SAMPLE IDENTIFICATION. This certification applies to the sample(s) identified below, which I have numbered and initialed (in the upper right hand corner of their first page) to correspond with the following listing. All production was done in the above identified plant, by the above identified firm, except for the supplied or subcontracted portions, if any, as listed. (If no exceptions,enter “None”.) Item No. Title or Description Production Exception(s) 1. 2. 3. 4. 5. (If necessary, continue on plain paper labeled: “Evaluation Sample Certificate”. Include date, firm name, and certifier’s name. Use the same numbers as in C.) D. CERTIFICATION. I am an officer, partner, or owner of the firm submitting the above listed sample(s); or have been listed as a contact person in the firm's registration information on file with the Government Publishing Office Contractor Connection https://contractorconnection.gpo.gov. I hereby certify that the above statements are true. This certification concerns a matter within the jurisdiction of an agency of the United States, and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under Title 18, United States Code, Section 1001. Name and Title Signature Date GPO Form 2689 08/16