RI Acknowledgment-Attorney in Fact 1

STATE OF RHODE ISLAND

COUNTY OF ____________

In [city/town] on this _______ day of __________, 20_____, before me personally appeared [name(s) of person(s) signing], attorney in fact for ________________ (the "Grantor"), to me known and known by me to be the party executing the foregoing instrument on behalf of the Grantor and acknowledged said instrument and the execution thereof, to be his/her free act and deed in said capacity and the free act and deed of the Grantor..

_________________________________

Notary Public

Printed Name: _____________________

My commission expires: _____________

No guidelines are available for this form at this time.