Submitting Agency:

Division:

Address:

Vendor:

Address:

Contract:

)

State of Illinois ) SS

County of )

)

I ______________, being duly sworn, solemnly (swear) (affirm) that: I am (give official title and office of affiant).

The attached contract was not filed within 30 days of execution because:

I am duly authorized to make this affidavit. This affidavit is made pursuant to and in fulfillment of the requirements of Section 15 of the State Comptroller Act. I know and understand the contents of this affidavit, and all statements herein are true and correct.

(Source: Added at 7 Ill. Reg. 5419, effective April 13, 1983)