Notary P ublic
On t his _ ________________ d ay o f _ __________________________, 2 0______ b efore m e,
__________________________________________ a n otary p ublic, p ersonally a ppeared
__________________________________________, w ho p roved t o m e o n t he b asis o f s atisfactory
evidence t o b e t he p erson(s) w hose n ame(s) i s/are s ubscribed t o t he w ithin
instrument a nd a cknowledged t o m e t hat h e/she/they e xecuted t he s ame i n
his/her/their a uthorized c apacity(ies), a nd t hat b y h is/her/their s ignatures o n t he
instrument t he p erson(s), o r t he e ntity u pon b ehalf o f w hich t he p erson(s) a cted,
executed t he i nstrument. I c ertify u nder P enalty o f P erjury u nder t he l aws o f t he
State o f _ _________________ t hat t he f oregoing i s t rue a nd c orrect.
Witness m y h and a nd O fficial S eal
_______________________________________________________________________
(Seal)
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