STATE OF ____
COUNTY OF____
Personally appeared before me, the undersigned authority in and for the said county and state, on this____ day of ____, 20____, within my jurisdiction, the within named ____, who acknowledged to me that (he) (she) is ____ of ____, a ____ corporation and member of ____, a ____ member-managed limited liability company, and that for and on behalf of said corporation as member of said limited liability company, and as the act and deed of said corporation as member of said limited liability company, and as the act and deed of said limited liability company, (he) (she) executed the above and foregoing instrument, after first having been duly authorized by said corporation and said limited liability company so to do.
My commission expires:
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For issuing guidelines on this form, see Guidelines.