STATE OF VERMONT
COUNTY OF ___________________, SS.
At __________, in said County, on this _________ day of __________, 20______, _________________________________, duly authorized agent of ___________________
(Name and Title) (Corporation)
personally appeared and he/she acknowledged this instrument, by him/her sealed and subscribed, to be his/her free act and deed of ________________________________.
(Corporation)
Before me, _________________________________
Notary Public
My commission expires: 2/10/03
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