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Attachment B

_____________________________________________
AGENCY LETTERHEAD
LIST OF BONDABLE PUBLIC OFFICERS

REMARSK
EFFECTIVE DATE AMOUNT (WITH/WITHOUT
NAME OF PUBLIC OFFICERS DESIGNATION RISK NO. PENIDNG CASE, STATE
FROM TO MAXIMUM BOND PREMIUM
NATURE OF CASE, if
any)

Prepared by: Certified and Approved by:

____________________________________ _________________________________________________
Signature Over-Printed Name Name & Designation of Authorized Official

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