State of ___________________
County of _________________
Before the undersigned, an officer duly commissioned by the laws of
____________, on this_____day of _____________, 20____, personally
appeared ______________________________ who having been first duly
sworn depose and say:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Witness:___________________ _________________________
Sworn and subscribed before me this ___day of ___________ 20____
