Commission Expires. Notary Public
Commission Expires. If the Affidavit is being made by a Beneficiary, a statement of the date of death of the Participant (and the Beneficiary in the case of the death of the Beneficiary receiving payments) must be added. I, _________________, under penalties of perjury, do hereby solemnly swear (i) that, pursuant to Section 4.2 of the Xxxxxxx Incorporated Grantor Trust For Senior Management Plans Trust Agreement between The Bank of New York (the “Trustee”) and Xxxxxxx Incorporated (the “Company”), as amended and restated as of [________], 2015 (the “Trust Agreement”), I am providing this Termination Affidavit to the Trustee and the Company in order to secure the benefits to which I (or the Participant) am entitled under such Trust Agreement and the Xxxxxxx Incorporated Top Hat Restoration Plan (the “Plan”); (ii) that a Termination (within the meaning of the Trust Agreement) occurred on _________ __, 20__ ; (iii) that the Participant [was/was not] deceased/that I [was/was not] in pay status as of the date of the Change of Control (as defined in the Plan); (iv) that I (or the Participant) am entitled to a [“Change of Control Retirement Benefit”] [Retirement Benefit other than a “Change of Control Retirement Benefit”] [Pre-Retirement Death Benefit] under the Plan. Participant’s Signature (1) ss.: On this ___ day of ____________, 20__, before me personally came _______________, to me known, who, being by me duly sworn, said that he\she resides at ____________________ __________________________ and that the statements herein are all true and correct. Notary Public
Commission Expires. If the Affidavit is being made by a Beneficiary, a statement of the date of death of the Participant (and the Beneficiary in the case of the death of the Beneficiary receiving payments) must be added.
Commission Expires. Notary Public (SEAL) NOTARIAL ACKNOWLEDGMENTS STATE OF VIRGINIA ) ) ss. COUNTY OF FAIRFAX ) I HEREBY CERTIFY that before me, a Notary Public duly commissioned and qualified in and for the above stated jurisdiction, personally came and appeared Xxxx X. Xxxxxxxxx, who after being duly sworn declared that he/she executed the foregoing UNWINDING AND STOCK EXCHANGE AGREEMENT as his/her free act and deed, and that the statements therein set forth are true and correct. Sworn to and Subscribed on November 29, 1999.
Commission Expires. Notary Public -------------------------------------------------------------------------------- STATE OF ___________________ ) ) ACKNOWLEDGMENT COUNTY OF _________________ )
Commission Expires. Notary Public EXHIBIT "A" LEGAL DESCRIPTION TO BE ATTACHED EXHIBIT "B" FLOOR PLAN TO BE ATTACHED EXHIBIT "C" BUILDING RULES & REGULATIONS
Commission Expires. Notary Public (SEAL) STATE OF VIRGINIA ) ) .ss COUNTY OF FAIRFAX ) I HEREBY CERTIFY that before me, a Notary Public duly commissioned and qualified in and for the above stated jurisdiction, personally came and appeared Xxxx X. Xxxxxxxxx, known to me to be the President of KEMRON ENVIRONMENTAL SERVICES, INC., a New York corporation, who after being duly sworn declared that he executed the foregoing UNWINDING AND STOCK EXCHANGE AGREEMENT as his free act and deed, and that the statements therein set forth are true and correct. Sworn to and Subscribed on November 29, 1999.
Commission Expires. Notary Public (SEAL) STATE OF ___________________ ) ) ss. COUNTY OF __________________ ) I HEREBY CERTIFY that before me, a Notary Public duly commissioned and qualified in and for the above stated jurisdiction, personally came and appeared XXXXXXX XXXXXX, who after being duly sworn declared that he/she executed the foregoing UNWINDING AND STOCK EXCHANGE AGREEMENT as his/her free act and deed, and that the statements therein set forth are true and correct. Sworn to and Subscribed on November 29, 1999.
Commission Expires. Notary Public ----------------------------- [NOTARY SEAL] STATE OF _____________ COUNTY OF _____________ I, __________________________, a Notary Public of the County and State aforesaid, certify that ________________________, a general partner of GOLDEN REALTY COMPANY, a general partnership, personally appeared before me this day and acknowledged the execution of the foregoing instrument as general partner on behalf of Golden Realty Company. Witness my hand and official stamp or seal this ___ day of April, 1997.
Commission Expires. Notary Public ----------------------------- [NOTARY SEAL] STATE OF _____________ COUNTY OF _____________ I, __________________________, a Notary Public for the above State and County, hereby certify that ________________________ personally came before me this day and acknowledged that she/he is __________________ Secretary of Ansexx Xxxxxx Xxxustrial Inc., a Delaware corporation, and that by authority duly given and as the acts of said corporation, the foregoing instrument was signed in its name by its President, sealed with its corporate seal and attested by him/her as its ________________ Secretary. Witness my hand and official seal, this the ___ day of April, 1997.
