Form Fmaa - Annual Report Of Premiums And Taxes Of All Fermers Mutual Aid Associations - 2011 Page 4

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NAIC________ COMPANY NAME_____________________ 2011 FORM AID AC FMAA-T
AFFIDAVIT
State of _______________________
County of ______________________
Comes____________________________________________ and states on oath that he/she is the
____________________________ of _________________________________________________
(Title)
(Name of Company)
and that the foregoing statements are true and correct as shown by the records of said Company.
_______________________________________
(Original Signature of Officer)
Subscribed and sworn to or affirmed before me, the undersigned Notary Public, on this
the _____day of_________, 20___.
_____________________________________
NOTARY PUBLIC
My Commission Expires_____________________________________
FEDERAL TAX ID NUMBER 71-0847443
Page 2 of 2
REVISED 2011

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