Specifications

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Solicitation XXX – Appendix _ - Sample Contract
Service Provided
Location
INDIVIDUAL, CORPORATION, PARTNERSHIP, OR LLC ACKNOWLEDGMENT
STATE OF 
: SS.:
COUNTY OF 
On the ____ day of ___________________ in the year 20 __ , before me personally appeared
_______________________________________ , known to me to be the person who executed the foregoing instrument, who, being duly
sworn by me did depose and say that _he resides at _____________________________________________________________,
Town of ______________________________________________ , County of _______________________________ , State of
______________________________ ; and further that:
[Check One]
( If an individual): _he executed the foregoing instrument in his/her name and on his/her own behalf.
( If a corporation): _he is the _________________________________ of
____________________________________ , the corporation described in said instrument; that, by authority of
the Board of Directors of said corporation, _he is authorized to execute the foregoing instrument on behalf of the
corporation for purposes set forth therein; and that, pursuant to that authority, _he executed the foregoing
instrument in the name of and on behalf of said corporation as the act and deed of said corporation.
( If a partnership): _he is the ________________________________ of
___________________________________, the partnership described in said instrument; that, by the terms of
said partnership, _he is authorized to execute the foregoing instrument on behalf of the partnership for purposes
set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and
on behalf of said partnership as the act and deed of said partnership.
( If a limited liability company): _he is a duly authorized member of ________________________________,
LLC, the limited liability company described in said instrument; that _he is authorized to execute the foregoing
instrument on behalf of the limited liability company for purposes set forth therein; and that, pursuant to that
authority, _he executed the foregoing instrument in the name of and on behalf of said limited liability company
as the act and deed of said limited liability company.
Notary Public
Registration No. State of: