Notary Form Certificate

							                MISSISSIPPI DEPARTMENT OF EDUCATION

  NOTARY PUBLIC FORM I-9 INFORMATION VERIFICATION CERTIFICATE


      On, _______________, 20__, in the State of_________________________
                (date)

County of ______________________, _________________________________
                                     Name of potential employee

Personally submitted to me,

_________________________________________________
            Name of Notary Public

I attest, under the penalty of perjury, that I have examined the documents(s)
listed. (See “Lists of Acceptable Documents” located on reverse of Department
of Homeland Security – Employment Eligibility Verification Form I-9).

                              LIST A DOCUMENT

________________________________________________________________________
Document Title (Date if any)                          /Issuing Authority

________________________________________________________________________
Document #                          /Exp.

                                    OR

                              LIST B DOCUMENT


________________________________________________________________________
Document Title (Date if any)                            /Issuing Authority

________________________________________________________________________
Document #                          /Exp.
                                        AND

                                LIST C DOCUMENT


________________________________________________________________
Document Title (Date if any)                      /Issuing Authority

________________________________________________________________
Document #                      /Exp.


These documents were presented by the above-named person and appear to be
genuine and relate to this person.

                            Witness my hand and seal.

   State of _____________________

   County of ___________________


   Subscribed and sworn before me this _______ day of _____________, 20__,


                                                  __________________________
                                                  Notary Public

                                                  My commission expires:




This form must be stamped with the notary seal and accompany a completed Form I-9 that
is signed by the notary.