STATE OF ____
COUNTY OF ____
Personally appeared before me, the undersigned authority in and for the said county and state, on this ____ day of ____, 20____, within my jurisdiction, the within named ____, who acknowledged that (he) (she) is ____ of ____ and that in said representative capacity (he) (she) executed the above and foregoing instrument, after first having been duly authorized so to do.
My commission expires:
(Affix official seal, if applicable)
For issuing guidelines on this form, see Guidelines.