Conn. Agencies Regs. § 11-8-17
The selectmen or administrative head shall, on or before December thirtieth of each year, file a summary statement as defined by section 11-8-14(g) of these regulations and a certificate with the public records administrator that the examination of the indexes and inspection of the records have been completed pursuant to Section 7-14 of the General Statutes.
Such certificate shall be in the following form:
CERTIFICATE
THE SELECTMEN/ADMINISTRATIVE HEAD OF THE CITY/TOWN HEREBY CERTIFY TO THE PUBLIC RECORDS ADMINISTRATOR THAT THE EXAMINATIONS OF INDEXES AND INSPECTIONS OF RECORDS AS REQUIRED BY SECTION 7-14 OF THE GENERAL STATUTES OF CONNECTICUT HAVE BEEN COMPLETED FOR THE PERIOD JANUARY 1, 19 TO DECEMBER 30, 19 .
Selectmen or Administrative Head
________________________________________
________________________________________
________________________________________
________________________________________
Subscribed and sworn to before me this ________ (day) _________ Month of 19_____ .
Notary Public
Commissioner of the Superior Court
Conn. Agencies Regs. § 11-8-17