Release For Property Damage In Auto Accident (Fillible) Page 3

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Certificate of Acknowledgment of Notary Public
State of _______________________________
)
)
ss
County of _____________________________
)
On _____________________, before me, ______________________________, a notary
public in and for said state, personally appeared ___________________
________________________, personally known to me (or proved to me on the basis of
satisfactory evidence) to be the person whose name is subscribed to the within
instrument, and acknowledged to me that he or she executed the same in his or her
authorized capacity and that by his or her signature on the instrument, the person, or the
entity upon behalf of which the person acted, executed the instrument.
WITNESS my hand and official seal.
_____________________________________
Notary Public for the State of ______________
My commission expires __________________
[NOTARY SEAL]
Release for Property Damage in Auto Accident
Page 3

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