State of _______________ )
County of ____________ )
This instrument was acknowledged before me on (date) by (name(s) of person(s)) as (type of authority, e.g., officer, trustee, etc.) of (name of party on behalf of whom instrument was executed).
________________________ (Signature of notarial officer)
(Seal, if any)
Title (and Rank)
My commission expires: _________________
No guidelines are available for this form at this time.