NAC693A.560. Signature of statements.

The statement must be dated and signed in substantially the following manner:

I certify that all the information contained in this statement is true, complete and correct, to the best of my knowledge and belief.

.................................................................                      ...........................................................

                                     (Date)                                                         (Signature of participant or

                                                                                                         authorized representative)

     [Comm’r of Insurance, Schedule B item 5, eff. 5-13-72]