Certification Page by 55sFeu

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									                              ANNUAL REPORT


                                  (name of city/town/county/district)




                                               0000
                                             MCAG No.




                               Submitted pursuant to RCW 43.09.230
                                              to the
                                  STATE AUDITORS OFFICE


                         FOR THE FISCAL YEAR ENDED DECEMBER , 2010




Certified correct this        day of                , 20 xx, to the best of my knowledge and belief:

GOVERNMENT INFORMATION:
Official Mailing Address
Official Web Site Address
PREPARER INFORMATION and CERTIFICATION:
Preparer Name and Title
Contact Phone Number
Contact Fax Number
Contact E-mail Address
Signature

								
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