NY Acknowledgment - Outside NY

State of ______________)
                                         ) ss:
County of ____________)

On the __________ day of ____________________ in the year ____________ before me, the undersigned, personally appeared _______________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledge to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument, and that such individual(s) made such appearance before the undersigned in the _________________________________ (add the city or political subdivision and the state or country or other place the acknowledgment was taken).

                                                                                                ________________________
                                                                                                             Notary Public