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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.