State of
County of
On this, the day of , 200_ , before me , the undersigned officer, personally appeared , known to me (or satisfactorily proven) to be a member of the bar of the highest court of Pennsylvania and a subscribing witness to the within instrument, and certified that he was personally present when whose name is subscribed to the within instrument executed the same, and that said person acknowledged that he executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
Notary Public
No guidelines are available for this form at this time.