State of _____________________
County of ___________________
The foregoing instrument was acknowledged before me this _____ (date) _____ by _____ (name of attorney-in-fact) _____ as attorney-in-fact on behalf of _____ (name of principal) _____.
________________________________________________
(signature of person taking acknowledgment)
(title or rank)
(serial number, if any)
No guidelines are available for this form at this time.