Annual Gross Revenue Return Form And Statement Of Assessment Due - Office Of Public Carrier Regulations Of Delaware Department Of Transportation Page 2

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ANNUAL REPORT 2006
AFFIDAVIT
CERTIFICATION
Subscribed and sworn to before me THE INFORMATION REPORTED ABOVE IS TRUE AND
CORRECT this _____ day of ______________________, 20___.
__________________________________
_______________________________
(SIGNATURE)
(SIGNATURE OF INDIVIDUAL
OR OFFICER)
OFFICIAL SEAL
________________________________
(TRADE OR CORPORATE NAME OF
CARRIER)
___________________________________
(OFFICIAL TITLE)
_________________________________
(ADDRESS - IF DIFFERENT FROM
ABOVE)
___________________________________
(DATE COMMISSION EXPIRES)
__________________________________
(SIGNATURE OF PREPARER IF OTHER
THAN ABOVE)

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