POA-1 (9/10) Page 3 of 4
Taxpayer’s identification number
Acknowledgment — individual
State of
ss:
County of
On this
day of
,
,
before me personally
came,
to me known to be the person(s) described in the foregoing power of attorney;
and he/she/they acknowledged that he/she/they executed the same.
Signature of notary public
Date
Notary public: affix stamp (or other indication of your notary authority)
Acknowledgment — corporate
State of
ss:
County of
On this
day of
,
,
before me personally
came,
to me known, who, being by me duly sworn, did say that he/she is
the
of
, the corporation described
in the foregoing power of attorney; and that he/she signed his/her name thereto by authority of the board of directors of said corporation.
Signature of notary public
Date
Notary public: affix stamp (or other indication of your notary authority)
Acknowledgment — limited liability company (LLC)
State of
ss:
County of
On this
day of
,
,
before me personally
came,
to me known, who, being by me duly sworn, did say that he/she is
a member or manager of the limited liability company described in the foregoing power of attorney; and that he/she is empowered to and
did execute the same.
Signature of notary public
Date
Notary public: affix stamp (or other indication of your notary authority)
Acknowledgment — partnership/limited liability partnership (LLP)
State of
ss:
County of
On this
day of
,
,
before me personally
came,
to me known, who, being by me duly sworn, did say that he/she is
a partner of the partnership described in the foregoing power of attorney; and that he/she is empowered to and did execute the same.
Signature of notary public
Date
Notary public: affix stamp (or other indication of your notary authority)
029003140094