Annual Gross Revenue Return And Statement Of Assessment - The Delaware Public Service Commission - 2015 Page 3

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AFFIDAVIT
CERTIFICATION
Subscribed and sworn to before me this
The information reported above is true
and correct.
__________ Day of _______________
20 ________.
____________________________________
Signature of Individual or Officer
____________________________________
Name of Signee (print or type)
________________________________
Signature
______________________________
Title of Signee (print or type)
NOTARY SEAL
____________________________________
Telephone Number of Signee
______________________________
____________________________________
Address of Signee
PREPARER INFORMATION
:
___________________________________
Signature of Preparer (if other than above)
________________________________
Official Title
______________________________
Name of Preparer (print or type)
____________________________________
________________________________
Title of Preparer (print or type)
Date Commission Expires
____________________________________
Telephone Number of Preparer
3

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