Bureau Of Securities Bond Form Page 3
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3Individual Acknowledgement
State of ___________________
ss.
County of __________________
On this _______ day of __________________ , _______, before me personally appeared ____________
______________________________________ , known by me to be the person described in and who
executed the foregoing instrument, as Principal, and acknowledged to me that he/she executed the same
as his/her free act and deed.
________________________________________
(Notary Public)
(Notarial Seal)
Residing at: ___________________________________
My Commission Expires: ________________________
LLC or Partnership Acknowledgement
State of ___________________
ss.
County of __________________
On this _______ day of __________________ , _______, before me personally appeared ____________
______________________________________ , known by me to be a member of the firm who executed
the foregoing instrument, and acknowledged to me that he/she duly executed the same as and for the act
and deed of said firm.
________________________________________
(Notary Public)
(Notarial Seal)
Residing at: ___________________________________
My Commission Expires: ________________________
Corporate Acknowledgement
State of ___________________
ss.
County of __________________
On this _______ day of __________________ , _______, before me personally appeared ____________
_________________________ , and says that he/she is the ___________________ of _____________
_________________________ , Principal heretofore named; that he/she executed the foregoing
instrument for and in its behalf, by authority of its Board of directors, and affixed its seal thereto.
________________________________________
(Notary Public)
(Notarial Seal)
Residing at: ___________________________________
My Commission Expires: ________________________
NOTE:
A true and correct copy of the applicable “Power of Attorney” must be attached hereto where the Bond is subscribed to by
an “Attorney in Fact.”
Page 3 of 3
Rev. 7/2014
Securities Bond Form2010.doc
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