11.4.2.9 NMAC, Revised 05/10/2017 AFFIDAVIT OF ANNUAL SAFETY INSPECTION STATE OF NEW MEXICO ) ) ss. COUNTY OF ) TO: Safety Program Manager Workers222 Compensation Administration PO Box 27198 Albuquerque, NM 87125-7198 I, , swear or affirm under penalty of perjury under the laws of New Mexico that the below information contained in this affidavit is true and correct: 1.I am the (job title) of (business name).2.The business has completed its annual safety inspection as required by statute.3.The following information is submitted as proof of annual safety inspection:a.Name of Business: b.Federal Employer Identification Number: c.Date(s) and Address(es) of Inspected Location(s) [include City and Zip code for each location]:*For additional locations please attach a separate list with site inspection information and address.d.Inspection(s) performed by: .e.For follow up and questions, contact:1)Name: 2)Phone: Email: Signature Date American LegalNet, Inc. www.FormsWorkFlow.com