On this ______day of ______, in the year 20____, before me,. Fill out, sign, and affix your official seal to the Notary certificate.The wording requirements for acknowledgment certificates vary from state to state. Download a notary acknowledgment form, available in PDF and Word format. On this _____ day of ______, in the year 20__, before me,. , personally appeared. Write the following statement verbatim in the space below. A form for the employee to sign acknowledging receipt of the policies. Following are samples of these provisions. Acknowledgment Letter.