State of _______________________
County of _____________________
On this the _______ day of ________, 20_______, before me, ____________________, the undersigned officer, personally appeared _____________________, known to me (or satisfactorily proven) to be the person whose name __________ subscribed to the within instrument and acknowledged that ____he____ executed the same for the purposes therein contained.
In witness whereof I hereunto set my hand and official seal.
Title of Officer
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