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Paper Printout Copy Certification of Electronic Record (IC 32-21-2.5.-12[d])

State of Indiana
County of ________

I certify that the foregoing and attached document entitled ____________________ (insert document title), dated ________ (insert document date) and containing ________ pages, is a true and correct copy of an electronic record printed by me or under my supervision. I further certify that, at the time of printing, no security features present on the electronic record indicated any changes or errors in an electronic signature or other information in the electronic record after the electronic record's creation or execution.

Signed this ________ day of ________ , ________.

_________ (signature of notarial officer)
_________ (printed name of notarial officer)
_________ (include notarial officer's commission number, official seal, commission county of residence or employment, and commission expiration date as required by applicable law)

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