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[] UNITED STAT~ FIRE INSURANCE COMPANY THE NORTH RIVER INSURANCE COMPANY [] WESTCHESTER FIRE INSURANCE COMPANY [] INTERNATIONAL INSURANCE COMPANY Please use corporate co~npany name exactly as it appears above .in completing th;: torm. CANC~.I-I,&TION EVIDENCE If payment of the renewal premium is refused because our principal is thought to have fulfilled his obligations under the bond, please have the appropriate section of this form completed, and return the form on or before the uremium anni- versary date of the bond. As proper cancellation evidence must be obtained eventually in the case o£ every bofid unrestricted as to term, initial compliance with this request will make unnecessary annoying correspondence, 1. (For Public Official Bonds) Bond No ..... :7.2_12...69. ................. TttI? CERTIFIEg THAT ............... R~bt~t..~k,..jRidga .......................................... ~....i ...................................... hereinafter called the Principal, o~n the .................... ./...g.. ................ day of ............ [.~...~.~ ............................. 19.7.?.., ceased to hold the office o/...../kaa~ss.or ............................................... of ..... g.~t0.$.~.y....~.o, wlash.tp. ................................... that the Principal hem turned over to his successor in office; who has duly qualiged, all moneys and other property pertaining to the office; and that the Principal's accou'nts for his full term of office have been examined and found correct. ........ ...... ............. ......... .............. ........... ' ...... (Official Title) 2. (For Prolmte Bondr, Administrator, Executor, Guardian, etc.) Bond No ........................................... In .................................................... Couri In the matter of the Estate of .................................................................. THI~c CERTIFIE? that on the ....................................................................day of ...................................... , 19 ......... the final account of .................................................................................. ~ ........................ as ........................................................ in the above-named estate was duly approved by this Court; that the said fiduciary has made return under oath that aJl money and property of the said estate .that have come into his possession, or under his co'ntro!, have been duly and properly paid and distributed; and that the fiduciary has been released by the Court and hi.~ bond has been diseharged. Dcaed : ................................................................................ Clerk. 30 (For Fidelity Bon&) The undersigned Employer hereby cancels Fidelity Bond No .......................................................... issued on or about the ............................................................... day ot .......................................................................................... , 19 ............. by Co?aeAu¥, as surety, in behalJ oI .................................................................................................................................................... and in Iavor oI the undersigned, such cancellation to be effective at noon on the .......................................... day oI ................................. ............................ 19 ............. and hereby releases COMPANY ]rom liability /or any and all acts o] the said employee or employees committed aIter the effective date oI cancellation stated above. Dated at ................................................................................................................................ this ....................................... day o~ ................................................................ 19 ............ If the Employer is a corporation this form is to be signed by its duly authorized officer; if a partner- ship, by a partner. FM. 205.00.61 n~.v. a/,~a (OVER} (Full name of employer) (Officers name and title, if a corporation; or full name of member of firm if a partnership.)