Page 107

State of Maryland Medical Assistance Manual Revised April 2014

Notary Certificate

STATE OF

COUNTY

I HEREBY certify that on the_______ day of ___________20 _______ , before me, the subscriber, a

(Month)

notary public of the state of

, in and for

the

, personally

[Insert the name of the city or county for which the notary is appointed]

appeared the above named signatory and duly executed the foregoing assignment of support rights.

As witnessed my hand and notary seal,

(Notary Public Signature)

[Notary Seal]

___________________________

Printed Name

My commission expires: _________________

(Date)