hereby certify to the following in connection with the forgoing (microfilm) (photographic reproduction):

That I am the official and lawful custodian of the records microfilmed or photographically reproduced and preserved in _________________________ (agency) as _________________________ identified and described as follows:

That the reason and authorization for this reproduction is as follows:

That certification is herein made pursuant to Section 12276 of the Government Code.

That this (microfilm) (photographic reproduction) of the above-described records was taken under my direction and control on ____________________, 20 ___, and that it is a complete, true, and correct copy thereof.

That the microfilming or other photographic processes were accomplished in a manner and on film which meets with the minimum standards or guidelines, or both, as recommended by the American National Standards Institute or the Association for Information and Image Management, and as adopted by the Secretary of State, for recording of permanent records or nonpermanent records.

That this certificate was made at the time of the taking of this (microfilm) (photographic reproduction).

In Witness Whereof, I have hereunto set my hand (and affixed my official seal) this _____ day of __________, 20 ___.