Free ManSig - Kansas

Our fees increased September 1, 2003. Please review the instruction box on the form for the new fee.

CERTIFICATE OF MANUAL SIGNATURE

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} ss COUNTY OF _______________ }
STATE OF KANSAS I,

Please complete the form, print, sign and mail to the Kansas Secretary of State with the filing fee. Selecting 'Print' will print the form and 'Reset' will clear the entire form.

(Please state office held)

of

County, Kansas, being duly sworn, do hereby certify

that the following is my official signature as used in the execution of a facsimile thereof, prepared and certified in accordance with Kansas Statutes Annotated 75-4001 to 75-4007. Signed:

Subscribed and sworn to me this _____ of __________________ , ______ .
Day Month Year

Notary Public

My commission expires _______________ . SEAL
Instruction
This form may be filed free of charge. If you would like a certificate verifing this manual signature please submit a $10 payment.

Notice: There is a $25 service fee for all returned checks.
Rev. 8/11/03 amc

60-03