County of ______________)
BE IT REMEMBERED, That on this ________ day of ______________ A.D., 20_____ before me, the undersigned, a Notary Public in and for said County and State, came ________________________________________________________ who _____ personally known to me to be the same person ___ who executed the within instrument of writing, and duly acknowledged the execution of the same.
IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal the day and year last above written.
My commission expires ______________ 20_____ ]
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