The certificate of acknowledgment (PDF) must be in the form set forth in California Civil Code section 1189. WITNESS my hand and official seal. Signature. (Seal).A notary public or other officer completing this certificate verifies only the identity of the individual. I am here doing a um mock notarization for an acknowledgement and durat i want to show you how to fill out both of them. To complete this HIPAA Acknowledgement Form, simply fill out the fields with the requested information. How to fill out the California All-Purpose Acknowledgment Form? Learn how to use a notary acknowledgment sample to ensure your legal documents are accurate, valid, and protected against fraud. San Diego Community College District. Social Security Number Acknowledgement Form. San Diego Community College District.