CERTIFICATION Form - Bureau of the Fiscal Service

Re: Award to: Claim No:

CERTIFICATION

I certify that I am the owner of the above award, and my current address is as follows:

__________________________________ __________________________________ __________________________________

___________________________________ Signature of Award Holder

Subscribed and sworn to before me a notary for and of the State of _______________________, this_______________, day____________, 20_____.

___________________________________ Notary Public

FS Form 2217

Department of the Treasury Bureau of the Fiscal Service

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