Specific Power Of Attorney Form Page 2

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WITNESS my hand and seal on this _____________ day of _______________________, 2016.
Witness:
____________________________
______________________________________
Name of Person Requesting POA
____________________________
Print name of witness
STATE OF: ________________________
COUNTY OF: ______________________
The foregoing instrument was acknowledged before me this ______ day of ________________,
2016, by ____________________________________________ who is personally known to me
or who has produced _____________________________________________ as identification.
________________________________
Notary Public
My commission expires: _______________________
Witnesses:
___________________________
______________________________________
Name of Person being Named POA
___________________________
Print name of witness
STATE OF: _____________________
COUNTY OF: ___________________
The foregoing instrument was acknowledged before me this ________ day of __________,
2016, by ____________________________________________ who is personally known to me
or who produced _________________________________________________ as identification.
________________________________
Notary Public
My commission expires: _______________________
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