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WIM-111A <br />Page 2 <br />STATE OF TEXAS § <br />COUNTY OF LAMAR § <br />BEFORE ME, the undersigned. notary, on this day personally appeared <br />— ------ the affiant, a J„)erson. whose identity is known. to me., After I administered <br />an oath. to affiant, affiant testified: <br />"My narne is i... . ..... I am capable of rnaking this verifl.cation. I have read. <br />the foregoing Certificate of Coml ' iliance/Non-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 cor)ies of those reports filed with theTexas <br />Workforce Comi-nission.” <br />Signature of Company Representative <br />Position/Title <br />Sworn to and subscribed before me this the — day of -- ........................—, 20—. <br />Notary Public, State of Texas <br />