"Certificate of Compliance With 10 Usc 4683"

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Certificate of Compliance with 10 USC § 4683
I, the undersigned, acting for and on behalf of______________________________________
(Name & complete address of Organization)
________________
_
, certify that:
1. The organization will use the rifles for funeral ceremonies of a member or former
member of the armed forces, or for other ceremonial purposes, and that the organization is
(check one):
___ a local unit of a nationally recognized veterans’ organization;
or
or
___ a unit/organization of honor guards for a national cemetery;
___ a law enforcement agency.
2. That the organization will use the rifles for (check all applicable reasons):
___ a funeral ceremony OF A MEMBER OR FORMER MEMBER OF THE
ARMED FORCES.
___a funeral ceremony for other than a member or former member of the
armed forces.
___a parade.
___other ceremonial purpose(s). Specify: _____________________________.
I hereby certify that to the best of my knowledge and belief that all statements above are true, correct, complete
and made in good faith. I understand and acknowledge that concealing material fact and/or making a false
statement is a violation of Title 18 USC§1001 and may result in the cancellation of the Conditional Deed for any
US Army property on loan to my organization and is punishable by fine or imprisonment.
SIGNATURE:_______________________________
NAME:____________________________________
(Typed or Printed)
TITLE:____________________________________
Notary Public Endorsement
COUNTY OF____________________________________STATE OF_____________
I, the undersigned, certify that I am a duly commissioned, qualified, and authorized notary public.
Before me personally and within the territorial limits of my warrant of authority, appeared the above
named individual, who is known by me to be the person who is described herein, whose name is
subscribed to, and who signed this Certificate of Compliance and who, having been duly sworn,
acknowledged that this instrument was executed after its contents were read and duly explained, and
that such execution was a free and voluntary act and deed for the uses and purposes herein set forth.
IN WITNESS WHEREOF, I have hereunto set my hand and affix my official seal on
this _____Day of __________________, 20___.
_____________________________________ My Commission expires:___________
Notary Public
Certificate of Compliance with 10 USC § 4683
I, the undersigned, acting for and on behalf of______________________________________
(Name & complete address of Organization)
________________
_
, certify that:
1. The organization will use the rifles for funeral ceremonies of a member or former
member of the armed forces, or for other ceremonial purposes, and that the organization is
(check one):
___ a local unit of a nationally recognized veterans’ organization;
or
or
___ a unit/organization of honor guards for a national cemetery;
___ a law enforcement agency.
2. That the organization will use the rifles for (check all applicable reasons):
___ a funeral ceremony OF A MEMBER OR FORMER MEMBER OF THE
ARMED FORCES.
___a funeral ceremony for other than a member or former member of the
armed forces.
___a parade.
___other ceremonial purpose(s). Specify: _____________________________.
I hereby certify that to the best of my knowledge and belief that all statements above are true, correct, complete
and made in good faith. I understand and acknowledge that concealing material fact and/or making a false
statement is a violation of Title 18 USC§1001 and may result in the cancellation of the Conditional Deed for any
US Army property on loan to my organization and is punishable by fine or imprisonment.
SIGNATURE:_______________________________
NAME:____________________________________
(Typed or Printed)
TITLE:____________________________________
Notary Public Endorsement
COUNTY OF____________________________________STATE OF_____________
I, the undersigned, certify that I am a duly commissioned, qualified, and authorized notary public.
Before me personally and within the territorial limits of my warrant of authority, appeared the above
named individual, who is known by me to be the person who is described herein, whose name is
subscribed to, and who signed this Certificate of Compliance and who, having been duly sworn,
acknowledged that this instrument was executed after its contents were read and duly explained, and
that such execution was a free and voluntary act and deed for the uses and purposes herein set forth.
IN WITNESS WHEREOF, I have hereunto set my hand and affix my official seal on
this _____Day of __________________, 20___.
_____________________________________ My Commission expires:___________
Notary Public