STATE OF _______________________________
(PARISH)(COUNTY) OF ___________________
BEFORE ME, the undersigned, a Notary Public in and for the aforesaid State and (County)(Parish), this day personally appeared _________________________, appearing herein in his capacity as the agent and attorney-in-fact for ____________________ (name of principal), to me personally known to be the identical person whose name is subscribed to the foregoing instrument as representing the said ________________________ (name of principal), and acknowledged to me in the presence of ________________________ and _______________________, competent witnesses, that [he][she] executed the same on the date thereof on behalf of _______________________ (principal), and that it was executed for the uses, purposes and considerations therein expressed by the authority of (Principal),as the free act and deed of the said ____________________________ (Principal).
THUS DONE AND PASSED in my office in the State and Parish aforesaid on this _____ day of __________________, 20____, after due reading of the whole.
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