Special Power Of Attorney (Page 4 of 5) in pdf

Special Power Of Attorney Page 4

Page 4 of 5

AFFIRMATION OF WITNESS

I, ____________________________________, affirm that ________________________

(13. Name of Witness)

(14. Name from Line 9)

appeared to be of sound mind and free from duress at the time this power of attorney was

signed, and that he or she affirmed that he or she was aware of the nature of this document and

signed it freely and voluntarily.

_____________________________________

15. Signature of Witness

(16. FOR USE BY NOTARY)

STATE OF _________________________

COUNTY OF _______________________, SS.

At __________________________ on the _________ day of ________________,

personally appeared __________________________________ who acknowledged this

(Name from Line 9)

instrument signed by him/her to be his/her free act and deed, and the free act and deed of

____________________________, before me,

(Name from Line 1)

__________________________________________

Notary Public

My Commission Expires: ______________________

Special Power Of Attorney Page 4