Addition To Exemption Application Form Page 3
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3Addition to Exemption
K.S.A. 79-201b Fourth
Page 3 of 3
VERIFICATION
I, ________________________________, do solemnly swear or affirm that the information set forth
herein is true and correct, to the best of my knowledge and belief. So help me God.
_______________________________________
Signature of Applicant
_______________________________________
Printed Name and Title
State of ____________________
)
County of __________________
)
This instrument was acknowledged before me on __________by________________________________.
Seal
______________________________________
Signature of Notary Public
My appointment expires: ________________
Revised 07/08
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