STATE OF ___________________, County of ______________________, ss
On this ________ day of ________________, in the year of _____, before me _______________________________________________, a notary public, personally appeared ________________________________________________________, known or identified to me to be the ______________________________________________ (official capacity) of the ______________________________________________ (name of state, county, city, etc.) that executed the said instrument, and acknowledged to me that such _________________________________________________________________ _______________________________________ (name of state, county, city, etc.) executed the same.
Notary Public: _______________________________________
Residing at: _________________________________________
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