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Form Il 482-0690 - Partnership Irrigation Contractorlawn Sprinkler Systems Surety Bond Page 2

Partnership Irrigation Contractor-

State of Illinois

Illinois Department of Public Health

Lawn Sprinkler Systems Surety Bond

A notary public must use this page to notarize the signatures

of individuals on the front of this bond.

Everyone must complete both Sections

Notarization of signature on front of bond for Partnership Irrigation Contractor

State of Illinois

)

) SS.

County of _________________________)

On this _____ day of ___________________, 20____, personally came _______________________________________

to me well known to be the identical person (s) described in and who executed the foregoing bond and he/she/they

acknowledged the same to be his/her/their own free act and deed.

___________________________________________________

_____/_____/__________

Notary Public

Date

(SEAL)

My commission expires: _____/_____/__________

Date

Notarization of signature on front of bond for Surety Company’s Attorney in Fact

(If an original Power of Attorney is attached this section is not required to be completed.)

State of Illinois

)

) SS.

County of _________________________)

On this _____ day of ___________________, 20____, personally came _______________________________________

to me personally known, who being by my duly sworn, did say that he/she is the attorney in fact, of

_______________________________________________, the surety company whose name is affixed to the foregoing

instrument; that the seal affixed to the foregoing instrument is the corporate seal of the said surety company; and that said

instrument was executed in behalf of said surety company by authority of its board of directors and said

______________________________________________ acknowledged that he/she executed said instrument as attorney

in fact as the free act and deed of said surety company.

___________________________________________________

_____/_____/__________

Notary Public

Date

(SEAL)

My commission expires: _____/_____/__________

Date

Important Notice

This State Agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under the Illinois Plumbing

Code. Disclosure of this information is mandatory pursuant to 77 IL Admin., Code 892.50. Failure to provide this form may result in suspension, denial

or revocation of the Irrigation Contractor Registration. This form has been approved by the Forms Management Center IL 482-0690.

IL 482-0690

IOCI 15-183