STATE OF RHODE ISLAND
COUNTY OF ____________
In [city/town] on this _______ day of __________, 20_______, before me personally appeared [name(s) of person(s) signing], [title(s)] of [name of corporation], to me known and known by me to be the party(ies) executing the foregoing instrument on behalf of said corporation, and acknowledged said instrument and the execution thereof, to be his/her/their free act and deed in said capacity and the free act and deed of said corporation.
Printed Name: _____________________
My commission expires: _____________
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