Ill. Admin. Code tit. 77, pt. 500, app E, ILLUSTRATION H
I, a Notary Public, in and for the said county, in the state aforesaid, do hereby certify that _______________ personally known to me to be the same person whose name is subscribed to the foregoing Information Exchange Authorization, appeared before me in person and acknowledged that he/she signed such authorization as his/her free and voluntary act and that the statements in such authorization are true.
Given under my hand and notarial seal on | _________________ | , | ___________ | ||
(insert date) | |||||
_________________________ |
SIGNATURE OF NOTARY |
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097 | |
VR 161.7 (rev. 05/2000) | Printed by Authority of the State of Illinois P.O.# 30M 02/00 |
Ill. Admin. Code tit. 77, pt. 500, app E, ILLUSTRATION H