State of _______________________
County of _____________________
On this the _______ day of ________, 20_______, before me, ____________________, the undersigned officer, personally appeared _____________________, of the state (county, city, or town as the case may be) of _________________, known to me (or satisfactorily proven) to be the person described in the foregoing instrument, and acknowledged that he executed the same in the capacity therein stated and for the purposes therein contained.
In witness whereof I hereunto set my hand and official seal.
Title of Officer
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