COUNTY OF _____________________
On this ______ day of _________, 20___, before me, personally appeared ___________, guardian of the property of ______________, incompetent, to me known to be the person described in and who executed the foregoing instrument, and who acknowledged the execution of same to be his free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and notarial seal.
My Commission expires:
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