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..
Printed Name: _____________________
My commission expires: _____________
No guidelines are available for this form at this time.