Free 34910.xls - Indiana


File Size: 330.7 kB
Pages: 1
Date: April 10, 2008
File Format: PDF
State: Indiana
Category: Government
Author: makidwell
Word Count: 141 Words, 903 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.in.us/icpr/webfile/formsdiv/34910.pdf

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SIGNATURE AFFIDAVIT
State Form 34910 (R3 3-08) / Form IC 113

INDIANA DEPARTMENT OF TRANSPORTATION

CONTRACT PROJECT

I,

, being duly sworn, do hereby authorize to sign any and all

ESTIMATE VOUCHERS and CONTRACT CHANGE ORDERS required, said individual(s) having full knowledge of all facts set forth in aforesaid payrolls.

I futher do hereby authorize to sign any and all copies of PAYROLLS required by the contract, said individural(s) having full knowledge of all facts set forth in aforesaid payrolls.

Name:
(FIRM OR CORPORATION)

By: (SIGNATURE)
(TITLE)

(NAME PRINTED OR TYPED)

ACKNOWLEDGEMENT State of Subscribed and sworn to before me this , County of day of ,20 SS:

(SIGNATURE)

(NOTARY PUBLIC)

(NAME PRINTED OR TYPED)

My Commission expires

,

20

* * * * * * * *
This form is to be completed by the contractor. The original and one copy be returned to the district office.