Hi, Lynne,
This sounds almost like the Certificates of Authenticity we used when we were microfilming records.  You might be able to find something using that language.  Here is a one I found after doing a search for Microfilm Certificate of Authenticity, once you go to this website you can click on the link to the form.
	https://urldefense.proofpoint.com/v2/url?u=http-3A__rm.sc.gov_microfilmservices_Pages_MfmCertificatesandFilmTargets.aspx&d=DwIFAg&c=pZJPUDQ3SB9JplYbifm4nt2lEVG5pWx2KikqINpWlZM&r=b5NZPQUb9_r2rQ3Zd74ATT3aSs9yKyRnJLOhqJvd7fE&m=2OT4VQ6hPIjZ7zQxVJ-N9K5OntVyHJp2SLP2KOc28Sk&s=D696fs5vz57Zo-RP_aVSltJHIzLDOFhIHKOM5hmYWqs&e=

Thanks,
Laurie

Laurie Sletten, CRM, CA
Records Manager
Information Technology Services
University of California - Office of the President
[log in to unmask]
Phone: (510) 987-9411
UC-Wide Records Management 
UC-Office of the President Records Management Services
https://urldefense.proofpoint.com/v2/url?u=http-3A__recordsretention.ucop.edu_&d=DwIFAg&c=pZJPUDQ3SB9JplYbifm4nt2lEVG5pWx2KikqINpWlZM&r=b5NZPQUb9_r2rQ3Zd74ATT3aSs9yKyRnJLOhqJvd7fE&m=2OT4VQ6hPIjZ7zQxVJ-N9K5OntVyHJp2SLP2KOc28Sk&s=CgVAEJYrFb_Gc8iY7XDjeTSvgZ1y5ol00R9ifdnkj10&e=

List archives at http://lists.ufl.edu/archives/recmgmt-l.html
Contact [log in to unmask] for assistance
To unsubscribe from this list, click the below link. If not already present, place UNSUBSCRIBE RECMGMT-L or UNSUB RECMGMT-L in the body of the message.
mailto:[log in to unmask]