Pledgee Agreement Form Page 2
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1
2Pledgee Agreement
(page 2 of 2)
Telephone: ____________________________
Print Name: _____________________________Title:_________
Fax:
____________________________
Signature:_______________________________Date:__________
The Undersigned hereby certifies that he/she is the present lawful incumbent of the designated public office.
Pledgee
____________________________________________
Name of governmental unit
____________________________________________
Street Address or P.O Box Number
____________________________________________
City, State, Zip Code
________________________________________
Date
Official Signature /
_____________________________________________
Printed Name and Title
Notary
State of _________________________
County of _______________________
On this _____ day of ___________, 20_
before me personally appeared
________________________________, to me personally known or satisfactorily proven, who by me duly sworn, did depose and say that
he/she resides at __________________________________________, in the City of __________________________________, in the
State of _______________________, that he/she is the _______________________________ [Title] of
_________________________________________ and that he/she executed this document on behalf of
_____________________________________ before me.
_______________________________
(Signature of Notary)
___________________________________
(Print name of Notary)
My commission expires on ________________________ [Date]
REV 01/2006
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