Statement Identifying Real Property Page 2
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1
2Real Property
Address
Tax Map Desgination:
Name of Municipality:
Section
Block
Lot
Signature of Guardian
Co-Guardian
Name of Guardian
Name of Co-Guardian
State of New York County of
} ss:
On this
day of
,
before me came
Name of Guardian
Name of Co-Guardian
to me know to be the individuals described herein, and who executed the foregoing instrument and
acknowledged that he/she/they executed same.
Notary Public
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