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Certificate of Compliance/Non-Compliance <br />.Page 2 <br />VE R.I.H.C.A112N <br />STATE OF TEXAS § <br />COUNTY OF LAMAR § <br />BEFORE ME, the undersigned notary, on this day personally appeared <br />, the affiant, a person whose identity is known to me. After I administered <br />an oath to affiant, afflant testified: <br />"My name is . I am capable of making this verification. I have read <br />the foregoing Certificate of Co mp liance/N on -Compliance. The facts stated in it are within <br />my personal knowledge and are true and correct, and I further certify that the Employer <br />Reference Summary pages are true and correct copies of those reports filed with the Texas <br />Wor <br />Sworn to and subscribed before me this the _,_ day of .. . ....... ­._­�� 20-- <br />