State of _______________________
County of _____________________
On this the _______ day of ________, 20 _______, before me, ____________________, the undersigned officer, personally appeared _____________________, who acknowledged himself to be the ______________________ of __________________, a corporation, and that he, as such _________________________, being authorized so to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself as _________________________________.
In witness whereof I hereunto set my hand and official seal.
Title of Officer
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