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 person whose name is subscribed to the within instrument as the attorney-in-fact of ______________________________________________ and acknowledged to me that __ he subscribed the name __ of _________________________ _______________________________________ thereto as principal, and ______ own name as attorney-in-fact.
Notary Public: _______________________________________
Residing at: _________________________________________
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