Form Wv/cem-4 - Preneed Cemetery Company Annual Report - 1999 Page 4

15.

AFFIRMATION FOR CORPORATION, SOLE PROPRIETORSHIP, OR PARTNERSHIP

I (we) do hereby certify that this Annual Report contains a true and accurate accounting and that all information

requested has been provided in complete and accurate detail, all as required by Article 5B, Chapter 35 of the

Code of West Virginia of 1931, as amended, and the regulations promulgated pursuant to such Act and the terms

of this reporting form.

Name ______________________________

(signature)

Title ______________________________

(Corporate Seal)

(If applicable)

Name ______________________________

(signature)

Title ______________________________

Taken, subscribed, acknowledged and sworn to before me this ____ day of ____________________, 19____.

My commission expires on _________________________________________________________________.

_______________________

Notary Public

(NOTARY SEAL)

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Parent category: Financial