Signature and certification required as follows:

SIGNATURE

Pursuant to the requirements of ch. Ins 57, Wis. Adm. Code,
__________has caused this notice to be duly signed on its behalf in the city of ____________and state of __________on the ____  day of __________, _____.

(SEAL) ___________________

(Name of Registrant)

BY ______________________

(Name and Title)

Attest:

_____________________

(Signature of Officer)

______________________ 

(Title)

The undersigned deposes and says that (s)he has duly executed the attached notice dated __________, _____, for and on behalf of_________________; and that (s)he is the ______________

(Name of Registrant)     (Title of Officer)

and that (s)he is authorized to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.

_________________________

(Signature)

_________________________

(Type or print name beneath)

Subscribed and sworn to this

_____day of _________, _____.

Notary Public _______________________________

My commission expires _______________________

FORM C

CONSENT TO JURISDICTION STATEMENT

Filed with the office of the commissioner of insurance,

state of Wisconsin

BY

______________________________________