Wage Payment Surety Bond Form - West Virginia Division Of Labor Page 3
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4Acknowledgment for Surety
24)
State of _________________________________)
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County of _______________________________), to-wit:
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I, __________________________________________________________, a Notary Public in and for the county
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and state aforesaid, do hereby certify that _________________________________________________, who, as
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___________________________________________________, signed the writing above or hereto annexed, for
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______________________________________________________________, a corporation, has this day, in my
said county before me, acknowledged the said writing to be the act and deed of said corporation.
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Given under my hand this _________ day of __________________________________________, 20 ______.
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_______________________________________________
Notary Public
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My Commission Expires __________________________________.
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Notary Seal
Approved as to sufficiency of form and manner of execution this
_______ day of ___________________, 20 ______.
_____________________________________________
Attorney General of the State of West Virginia
By: ______________________________________________
Chief Counsel
***Please note that page 4 must be completed before the bond can be approved by the Attorney General.
Page 3 of 4
WVAGO Approved Form
Last Revised 9/25/14
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