Insured'S Mitigation Verification Affidavit- Condominium Unit Owner Form (Page 2 of 2) in pdf

Insured'S Mitigation Verification Affidavit- Condominium Unit Owner Form Page 2

IMPORTANT NOTICE

Insurers have the right to confirm all information contained in this survey form via a survey of the risk.

Any person or insurer who makes a false statement or misrepresentation, and any other person

knowingly, with an intent to injure, defraud, or deceive, who assists, abets, solicits, or conspires with such

person or insurer to make a false statement or misrepresentation is subject to both criminal and civil

penalties pursuant to S.C. Code Ann. 38-55-540 and 38-55-550.

Certification

I hereby certify that the above marked mitigation or construction techniques have been implemented.

(Copies of the applicable receipts must accompany this affidavit.) This affidavit is intended only for the

purpose of the named insured’s receipt of a property insurance premium discount and for no other

purpose.

Policyowner’s Signature __________________________________________ Date_______________

(notarize below)

State of South Carolina

)

County of _____________________

)

With respect to the above,

The above named signatory has sworn to and subscribed before me this _______ day of ________, A.D.,

20__, by _____________________________ (name of person making the statement) the information

within this document is accurate and true. The above signatory is personally known to me

___________________________________ or produced ___________________________________

(type of identification) for identification.

_________________________________________________

Signature of Notary

_________________________________________________

Print, Type of Stamp Name of Notary

Insured'S Mitigation Verification Affidavit- Condominium Unit Owner Form Page 2