2024 FIRE DEPARTMENT SERVICE CERTIFICATION FORM SERVICE AWARD PROGRAM

Village of Red Hook

Red Hook Fire Company

Article 11-A of the New York State General Municipal Law requires that a list of volunteers indicating those who earned a year of Service Credit during 2024 be certified under oath and submitted to the Program Sponsor for approval by March 31, 2025. To comply with Article 11-A, please have the person responsible for preparing the 2024 Firefighter Records listing sign this form and have a notary witness the signature. The 2024 Data Request Package should then be presented to the Village Board prior to March 31, 2025.

CERTIFICATION

As required by Article 11-A, | certify under oath the attached is a list that includes all volunteers of the Fire Department and indicates the points earned by each volunteer in accordance with the Service Award Program Point System, which will be used to determine who will earn Service Credit for the 2024 calendar year.

==> picture [146 x 41] intentionally omitted <==

----- Start of picture text -----

fior cs Seve Signature ----- End of picture text -----

==> picture [261 x 41] intentionally omitted <==

----- Start of picture text -----

Do ») AE CA ot VA 4 F & | je [ Jaks Title — Date ----- End of picture text -----

NOTARY CERTIFICATE

State of New York

==> picture [379 x 69] intentionally omitted <==

----- Start of picture text -----

County of Dztebos$ Sworn to (or affirmed) and subscribed before me this (wT day of of Que py“ Thomas “Bagre . f ----- End of picture text -----

==> picture [226 x 140] intentionally omitted <==

----- Start of picture text -----

day of of Que ; 202S° ; . f i Signature of Notary lic Se r SS Covenan sb Printed Name of Notary Public, Notary Public My Commission expires: _letwyT-Ze2m ----- End of picture text -----

JENNIFER S CAVANAUGH NOTARY PUBLIC-STATE OF NEW YORK No. 01CA68442770 Qualified in Dutchess County My Commission Expires 10-17-2026

CERTIFICATION (GREEN)