Miss. Code. tit. 39, pt. 1, ch. 23, r. 39-1-23, exh. 39-1-23-24
AFFIDAVIT
STATE OF ______________________________
COUNTY OF ______________________________
On this _______________________ day of ___________________ , before me, the undersigned, a Notary Public in and for the State and County aforesaid, personally appeared ____________ , appearing herein in his capacity as ___________________ (Title) of ___________________ (Company) (the "Company") duly authorized to act on behalf of said Company, who being by me first duly sworn deposed and said that:
The foregoing instrument/Notice of Disconnect was received by said Company with an undisputed amount listed as (DollarAmount) due to the underlying carrier and a date of disconnect listed as (Date or Dates Specified).
He/She is appearing to swear or affirm that he/she will ensure, on behalf of said Company, that:
The Company can and will pay the undisputed amount owed to the underlying carrier at least five (5) calendar days prior to the disconnect date;
OR
The Company will mail notice of disconnection to its customers at least twenty (20) calendar days prior to the disconnection date as listed in the attached Notice from the underlying carrier (ATTACHMENT OF NOTICE REQUIRED.)
AND if I fail to do what I say that I will do (send notice or pay) then I forfeit the bond for failing to do as I have sworn I would do.
AND if present before the Commission and duly sworn, his/her testimony would be the same.
_____________________________________
Person duly authorized to act for the Company
SWORN TO AND SUBSCRIBED BEFORE ME THIS ________ DAY OF ____________________ , 20___.
NOTARY PUBLIC My Commission Expires: __________________________________
Miss. Code. tit. 39, pt. 1, ch. 23, r. 39-1-23, exh. 39-1-23-24