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Affidavit by producing broker... PART C AFFIDAVIT BY PRODUCING BROKER 1. PRODUCING BROKER INFORMATION AFFIDAVIT NO. License No. BR- Name Address City State Zip Code 2. RISK INFORMATION Name of the Insured The name of the insured must be precisely the same in this affidavit and the declarations page binder cover note or confirmation of coverage. 3. DISCLOSURE INFORMATION Yes No Did you personally provide a written Notice of Excess Line Placement Form NELP/2011 to the insured as ...

Ohio dbe annual affidavit form Annual Affidavit for DBE Certification SECTION 1 COMPANY INFORMATION 1. Legal name of business 2. Other names used by business 3. Website if have one 4. Federal tax ID 5. Company phone 8. E-mail communications 6. Other phone Yes 7. Company fax 9. County only if an Ohio company No 10. Street address of company No P. O. box City State Zip 11. That the Ohio Department of Transportation may deny certification or rescind certification and initiate action under Federal or State laws concerning false statements if during or after the certification process it finds that the undersigned has submitted false inaccurate or misleading information. implementation of the DBE eligibility standards despite the fact that said business may be certified by another entity. 7. That the firm meets the Small Business Administration SBA criteria for being a small business concern and its average annual gross receipts as defined by the SBA rules over the firm s previous three fiscal years do not exceed the work type limit. I recognize and accept the seven 7 statements above governing the consideration of this affidavit and the maintenance of my business certified status. DISADVANTAGED BUSINESS ENTERPRISE PROGRAM TITLE 49 OF THE CODE OF FEDERAL REGULATIONS PART 26 ANNUAL AFFIDAVIT The purpose of the annual affidavit is to identify owner or company changes that may effect DBE certification* This information is required to maintain or renew DBE certification* Contents Section 1 Company Information Section 2 Annual Affidavit Questions Section 4 Certification Information Section 5 Supporting Documents Checklist Affidavit of Certification To complete this document 1. Enter the Company Information in section 1. 2. Check the Yes/No boxes for section 2 Annual Affidavit Questions. Where required provide details. 3. Provide supporting documents as required in section 3 Supporting Documents Checklist. 4. Sign the Affidavit in the back of the document and have it notarized* 5. Submit the entire document with supporting documents to your certifying agent by the due date. Annual Affidavit for DBE Certification SECTION 1 COMPANY INFORMATION 1. Legal name of business 2. Other names used by business 3. Website if have one 4. Federal tax ID 5. Company phone 8. E-mail communications 6. Other phone Yes 7. Company fax 9. County only if an Ohio company No 10. Street address of company No P. O. box City State Zip 11. Mailing address of company if different Indicates required field for new applicants or new records. Section 1 Company Information Page 1 SECTION 2 ANNUAL AFFIDAVIT QUESTIONS 1. Has the ownership management or control of the company changed in any way in the past year If Yes please use section 3 the Company Owners and Representatives form to indicate modifications. 2. Have there been any investments or contributions of capital in the company over the past year If Yes please provide details under the Asset Transfers heading in section 4C. 3. Has the company or any of its owners board members officers or management been denied certification denied re-certification or been decertified as a DBE in the past year storage space in the past year If Yes please list those things that have been acquired or liquidated in section 4C.

Affidavit of support sample fo... Thank you for your interest in pursuing a degree at Wilmington University that offers both undergraduate and graduate programs at Wilmington University in a wide range of instructional areas. For

Nala recertification affidavit... NATIONAL ASSOCIATION OF LEGAL ASSISTANTS, INC. 1516 SOUTH BOSTON, SUITE 200, TULSA, OK 74119 918.587.6828 Fax: 918.582.6772 www.nala.org nalanet@nala.org Recertification Affidavit NOTE: This form

Affidavit of indigency florida... FINANCIAL DISCLOSURE / AFFIDAVIT OF INDIGENCY Applicant's Name Mailing Address Case No. ($25.00 application fee may be assessed--see notice on reverse side) I. PERSONAL INFORMATION D.O.B. Person Represented's

Affidavit of support clark uni... 1 000. 00 Total. 18 000. 00- 22 248. 00 Please add 3 000. 00 per each dependant on your application. Dependant Information Family Name First Name Date of Birth Country of Birth City of Birth Citizenship Relationship through personal or family sponsorship in the form of Original Bank Letter written on a bank letterhead or Original Bank Statement dated within past 3 months that includes the specific current amount in the USD and Letter From the Spo...

Shelby county affidavitpdffill... Shelby County Schools Shared Residence Affidavit This form is to be completed if residency requirements cannot be provided due to the fact that the parent and child ren are sharing a home with another person SEVEN DAYS A WEEK YEAR ROUND. I agree to notify Shelby County Schools if there is any change in the status of my residence. I understand that home visitation and/or residency verification is part of the process when residency is established by an Affidavit of Shared Residence. I agree to notify Shelby County Schools if there is any change in the status of residence of the persons listed above. I understand that home visitation and/or residence verification is part of the process when residency is established by a Shared Residence Affidavit. I understand that home visitation and/or residence verification is part of the process when residency is established by a Shared Residence Affidavit. I further agree to provide proof of my residence to Shelby County Schools. State of Tennessee County Of appeared Name s of Signer s Place Notary Seal below who proved 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. This affidavit must be re-certified through Student Services annually. All sections must be completed and signatures notarized* DO NOT SIGN THIS FORM IF ANY OF THE STATEMENTS ARE INCORRECT. Evidence of false information will result in immediate withdrawal of the student s from school* To be completed by Parent s / Guardian s Student Last Name First Name Sex M F Birth Date // Grade Please list additional students on a separate sheet. Parent s Name Address Telephone Cell Phone Other Phone This living arrangement is Temporary Duration Permanent This address listed above is my only residence. Signature of Parent/Legal Court Appointed Guardian TN Driver s License/ID Card Number Date TO BE COMPLETED BY HOMEOWNER Owner Lease Holder Qualified Relative Friend Neighbor etc* Street City Zip reside with me on a full time basis seven days a week year round. I agree to notify Shelby County Schools if there is any change in the status of residence of the persons listed above. I understand that home visitation and/or residence verification is part of the process when residency is established by a Shared Residence Affidavit. I further agree to provide proof of my residence to Shelby County Schools. State of Tennessee County Of appeared Name s of Signer s Place Notary Seal below who proved 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.

Affidavit of fact form AUSTIN, TX 78751. OF TAXES. Phone: (512) ... NO ALTERATIONS, WHITEOUT OR ERRORS ARE ACCEPTABLE ON THIS FORM. This is to state that an error ...

Tree affidavit form Is exempt from the Tree Preservation Ordinance Rights Determination is required Aka Vested Rights Permit For Residential Building Permit Tree Affidavit a 35 Review Fee and aerial photo of project area is required. All other reviews require a 250 fee and an aerial photo of project area. OR 4. D.C. and all related appendices regarding Tree Preservation and agree to adhere to the requirements including any additional fees determined to be owed to complete this permit. State of Texas County of Bexar Signature known to me to be the Before me the undersigned authority on this day personally appeared person whose name is signed to the foregoing affidavit and sworn by me states under oath that all of the facts therein set forth are true and correct. A/P City of San Antonio Development Services Department 1901 S. Alamo San Antonio TX 78204 TREE AFFIDAVIT / PERMIT APPLICATION Office Use Only INSPECTOR INITIALS DATE APPROVED NOT APPROVED PASS / FAIL INITIALS Project Address/Location Outside City Limits Project Name/Subdivision Class of Work Check as Appropriate Tree Removal Project Type Check as Appropriate Company ID Lot No. Site Work Block Platting Commercial acres New Structure Addition 2500 ft Residential lots Contact ID Public Funds Used Contact Person N Plat NCB/CB Unit Parcel Key http //maps. sanantonio. gov/imf/sites/DevServices/jsp/launch. jsp Y Company Name Email Phone Fax Owner Address Stat City Zip APPLICANT SHALL PROVIDE HABITAT COMPLIANCE FORM AS DEFINED IN 35-B133 FOR PROPERTIES 2. 0 ACRES AND LARGER. IF A MASTER TREE PERMIT TREE PLAN OR A TREE PERMIT ASSOCIATED WITH A RIGHTS DETERMINATION REVIEW WAS PREVIOUSLY APPROVED PROVIDE AP if acknowledging a previously approved tree permit as noted above no selection of 1-4 is required below PLEASE MARK THE APPROPRIATE BOX FOR REVIEW ONLY MARK ONE BOX 1. has no Protected Significant Heritage or Historic trees as defined in Article V 35-523 or 35-6111 of the U. D*C* Aerial photo required for 2003/2006 Ordinance OR 2. has protected trees but this work will in no way cause damage to or the destruction of said trees I understand such is a direct violation of the provisions of Article V 35-477B b 2 or 35-6106 Aerial photo or Tree Survey required for 2003/2006 Ordinance OR 3. has Protected Significant Heritage or Historic trees that will be removed* Requires additional site plan and tree inventory submitted I agent/owner certify that I am aware of Article V 35-523 of the U. D*C* and all related appendices regarding Tree Preservation and agree to adhere to the requirements including any additional fees determined to be owed to complete this permit. State of Texas County of Bexar Signature known to me to be the Before me the undersigned authority on this day personally appeared person whose name is signed to the foregoing affidavit and sworn by me states under oath that all of the facts therein set forth are true and correct. Sworn To Before me this day of http //www. sanantonio. gov/dsd/environmental*asp. Notary Public In And For The State of Texas.

Affidavit of birth information... Affidavit of Birth Information for Out-of-Hospital Births This Affidavit is to be Completed at the Local Health Office I swear or affirm that the information stated is true and correct to the best of my knowledge and belief. I certify that the child named herein was born alive to the stated mother at the place date and time shown on this worksheet.

Notice of death affidavit illi... NOTICE OF DEATH AFFIDAVIT AND ACCEPTANCE OF TRANSFER ON DEATH INSTRUMENT Prepared by and return to Send subsequent tax bill to The undersigned beneficiary or beneficiaries being duly sworn on oath state as follows That died on Name of Owner County Month Day Year a resident of owning residential real estate legally described below State Legal Description attach exhibit if more room is needed That the street address of the residential real estate is is City Property Identification Number PIN ATG FORM 3056 ATG REV. 3/13 Document No. Zip. That the Transfer on Death Instrument is dated No. Street Address in the Office of the Recorder for and the property identification number and recorded as Document Date County Illinois. NOTICE OF DEATH AFFIDAVIT AND ACCEPTANCE OF TRANSFER ON DEATH INSTRUMENT Prepared by and return to Send subsequent tax bill to The undersigned beneficiary or beneficiaries being duly sworn on oath state as follows That died on Name of Owner County Month Day Year a resident of owning residential real estate legally described below State Legal Description attach exhibit if more room is needed That the street address of the residential real estate is is City Property Identification Number PIN ATG FORM 3056 ATG REV. 3/13 Document No* Zip. That the Transfer on Death Instrument is dated No* Street Address in the Office of the Recorder for and the property identification number and recorded as Document Date County Illinois. FOR USE IN IL Page 1 of 2 That the undersigned whose names and addresses appear below are all beneficiaries entitled to receive under the Transfer on Death Instrument Name Address Share In witness whereof the undersigned beneficiaries hereby accept the transfer of residential real estate under the transfer on death instrument this of Signature of Beneficiary Name Print STATE OF ILLINOIS SS COUNTY OF Name s of Beneficiary ies personally known to me to be the same person or persons whose name or names are subscribed to the foregoing instrument appeared before me this day in person and swore on oath to the above foregoing affidavit. 3/13 Document No* Zip. That the Transfer on Death Instrument is dated No* Street Address in the Office of the Recorder for and the property identification number and recorded as Document Date County Illinois. FOR USE IN IL Page 1 of 2 That the undersigned whose names and addresses appear below are all beneficiaries entitled to receive under the Transfer on Death Instrument Name Address Share In witness whereof the undersigned beneficiaries hereby accept the transfer of residential real estate under the transfer on death instrument this of Signature of Beneficiary Name Print STATE OF ILLINOIS SS COUNTY OF Name s of Beneficiary ies personally known to me to be the same person or persons whose name or names are subscribed to the foregoing instrument appeared before me this day in person and swore on oath to the above foregoing affidavit.

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