Free SIGNATURE VERIFICATION FORM - Virginia

SIGNATURE VERIFICATION FORM

Principal: _________________________________________________ Name of Lobbyist: _________________________________________ Note: Each lobbyist and principal must execute a signature certification form for each disclosure statement. Both the lobbyist and principal officer must sign this signature verification form, attesting to the completeness and accuracy of the disclosure statement filed electronically or by diskette. The following items are mandatory, and if they are not properly completed, the entire filing will be rejected. (1) All signatures on this form must be ORIGINAL in the format specified in the instructions provided by the Secretary that accompany this form. No stamp, or other reproductions of the individual's signature will be accepted. An individual MAY NOT sign this form as lobbyist and principal officer. STATEMENT OF LOBBYIST I, the undersigned registered lobbyist, do state that the information furnished on my disclosure statement on behalf of the above-stated principal, and on all accompanying attachments required to be made thereto, to the best of my knowledge and belief, is complete and accurate. _____________________________________ Signature of Lobbyist STATEMENT OF PRINCIPAL I, the undersigned principal (or authorized official thereto), do state that the information furnished on the disclosure statement for the above-stated principal, and on all accompanying attachments required to be made thereto, to the best of my knowledge and belief, is complete and accurate. _____________________________________ Signature of Principal ____________ Date ____________ Date

(2)