STATE OF ________________
COUNTY OF ______________
Before me ______________________ (here insert the name and character of the officer) on this day personally appeared ________________________, known to me (or proved to me on the oath of _______________________ ) to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purposes and consideration therein expressed.
Given under my hand and seal of office this _____________ day of __________, A.D.,
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