Form For Disposition Of Securities Belonging To A Decedent'S Estate Being Settled Without Administration Page 7

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Certifying Officer - The individuals must sign in your presence. You must complete the certification and affix your stamp or seal.
I CERTIFY that
, whose identity is known or was
,
proven to me, personally appeared before me this
day of
,
(Month)
(Year)
, and signed this form.
at
(City)
(State)
(Signature and title of certifying officer)
(OFFICIAL STAMP
OR SEAL)
(Number and Street or Rural Route)
(Ci y)
t
(State)
(ZIP Code)
I CERTIFY that
, whose identity is known or was
,
proven to me, personally appeared before me this
day of
,
(Month)
(Year)
, and signed this form.
at
(City)
(State)
(Signature and title of certifying officer)
(OFFICIAL STAMP
OR SEAL)
(Number and Street or Rural Route)
(Ci y)
t
(State)
(ZIP Code)
I CERTIFY that
, whose identity is known or was
,
proven to me, personally appeared before me this
day of
,
(Month)
(Year)
, and signed this form.
at
(City)
(State)
(Signature and title of certifying officer)
(OFFICIAL STAMP
OR SEAL)
(Number and Street or Rural Route)
(Ci y)
t
(State)
(ZIP Code)
I CERTIFY that
, whose identity is known or was
,
proven to me, personally appeared before me this
day of
,
(Month)
(Year)
, and signed this form.
at
(City)
(State)
(Signature and title of certifying officer)
(OFFICIAL STAMP
OR SEAL)
(Number and Street or Rural Route)
(Ci y)
t
(State)
(ZIP Code)
I CERTIFY that
, whose identity is known or was
,
proven to me, personally appeared before me this
day of
,
(Month)
(Year)
, and signed this form.
at
(City)
(State)
(Signature and title of certifying officer)
(OFFICIAL STAMP
OR SEAL)
(Number and Street or Rural Route)
(City)
(State)
(ZIP Code)
PD F 5336

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