STATE OF ________________, COUNTY OF _________________, ss.
On this _______ day of ______________, in the year of ______, before me _________________________________________________________, a notary public, personally appeared _________________________________________________,
known or identified to me to be the person _ whose name __ _________________________________________________________________ subscribed to the within instrument, and acknowledged to me that __ he __ executed the same.
Notary Public: ________________________________________________
Residing at: ___________________________________________________
My Commission Expires: ________________________________________
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