UC-423 (Rev. 7/03) 
  
                                        STATE OF CONNECTICUT 
                                        DEPARTMENT OF LABOR 
         200 FOLLY BROOK BOULEVARD, WETHERSFIELD, CT  06109-1114 
                                                     
                                        Guarantee Affidavit 
                                                     
 STATE
                                                             ss.
 COUNTY OF                                                             (City)                (Date)
     
 PERSONALLY APPEARED                                                                         being 
                                                                (Name)                        
  
                             of
         (Title)                                                 (Name of Corporation) 
  
 who, being duly sworn, deposes and says:           
  
 1.  He or she is the                                        of      
                                        (Title)                        (Name of Corporation) 
  and is duly authorized to execute the affidavit in behalf of the corporation. 
  
 2.  Said corporation assumes liability for and guarantees the filing of all tax returns due to the State of  
   Connecticut from                                          as well as full payment of all taxes lawfully  
                             (Name of Corporation)            
  assessed with respect to any taxable period during which the company was subject to such taxes in 
  accordance with the provisions of the Connecticut General Statutes, Department of Labor 
  Regulations and policies. 
  
 3.  The                                discontinued/transferred business operations in Connecticut on or  
                  (Name of Corporation)         (Circle one)     
  about                                 and has held no property in said state since   
                      (Date)                                                           (Date)
   
 4.  It is stipulated and agreed that this commitment to pay any taxes legally assessed and due from 
  said corporation shall not be affected by the granting of a Clearance Certificate for the Secretary of 
  the State of Connecticut. 
  
                                                                    (Signature and Title of Principal Officer)   
  
 Subscribed and sworn before me this                         day of                          20                 
  
                                                                       Notary Public