For the following applicant: ________________________________________________________________ NAME OF BUSINESS ____________________________________________________________________________________________ ADDRESS PHONE ____________________________________________________________________________________________ CITY STATE ZIP CODE COUNTY hereby certify that the Applicant named has at least $2,000,000 in capital, $500,000 of which is on deposit with one or more financial institutions, as follows (capital may include cash or securities, real estate, or other assets): Type of Source of Total Value not If on deposit, If on Capital Capital Value of encumbered name and deposit, Capital by debt or address of account other financial number obligations institution I hereby certify that I am authorized to execute this affidavit on behalf of the applicant and that the information contained herein is true and correct and that is no misrepresentation, falsification or omissions in this affidavit. I am further aware that any false or misleading statement or omitted information is punishable under the applicable provisions of 18 Pa. C.S. Ch. 49 (relating to falsification and intimidation). ___________________________ __________ Signature of Affiant and Title Date
For the following applicant: ________________________________________________________________ NAME OF BUSINESS ____________________________________________________________________________________________ ADDRESS PHONE ____________________________________________________________________________________________ CITY STATE ZIP CODE COUNTY hereby certify that the Applicant named has at least $2,000,000 in capital, $500,000 of which is on deposit with one or more financial institutions, as follows (capital may include cash or securities, real estate, or other assets): Type of Capital Source of Capital Total Value of Capital Value not encumbered by debt or other obligations If on deposit, name and address of financial institution If on deposit, account number I hereby certify that I am authorized to execute this affidavit on behalf of the applicant and that the information contained herein is true and correct and that is no misrepresentation, falsification or omissions in this affidavit. I am further aware that any false or misleading statement or omitted information is punishable under the applicable provisions of 18 Pa. C.S. Ch. 49 (relating to falsification and intimidation). ___________________________ __________ Signature of Affiant and Title Date