Ill. Admin. Code tit. 50, pt. 1705, exh. A

Current through Register Vol. 48, No. 44, November 1, 2024

Exhibit A - Certificate of Compliance

STATE OF

___________________

)

)

SS

COUNTY OF

________________

)

______________________________________

___(Official's name)___________, being first duly sworn, deposes and says that:

1. He is the _____(Official title)_____________ of the ____(Name of fraternal benefit society) ___________, a fraternal benefit society formed under the laws of the State of;

2. He is the duly appointed official custodian of the Articles of Incorporation or Association, Constitution, By-laws, Rules and Regulations of said Society; and

3. The certificate(s) rider(s) or endorsement(s) hereto and filed for approval herewith are in full compliance with the provisions and requirements of those Articles of Incorporation or Association, Constitution, By-laws, Rules and Regulations.

________________________________ (Official Title)

Subscribed and sworn to

before me this

___

day of

____________________,

19

________________.____________________

________________________

Notary Public ____________________________

My Commission expires _________, 19 ___ .

Ill. Admin. Code tit. 50, pt. 1705, exh. A