COUNTY OF
On this ______ day of __________________, 200_, before me, the undersigned officer, personally appeared ___________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed as agent under a Power of Attorney for _____________________, Principal, and acknowledged that he/she executed the same as the act of Principal for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
_________________________________
Notary Public
Notarial Seal
No guidelines are available for this form at this time.