STATE OF

)

)

SS

COUNTY OF

)

(Official's name)

, being first duly sworn, deposes and says that:

1.  He is the

(Official title)

of the

(Name of fraternal benefit society)

,

a fraternal benefit society formed under the laws of the State of

;

2.  He is the duly appointed official custodian of the Articles of Incorporation or Association, Constitution, By-laws, Rules and Regulations of said Society; and

3.  The certificate(s) rider(s) or endorsement(s) hereto and filed for approval herewith are in full compliance with the provisions and requirements of those Articles of Incorporation or Association, Constitution, By-laws, Rules and Regulations.

(Official Title)

Subscribed and sworn to

before me this

day of

,

19

.

Notary Public

My Commission expires

,

19

.