Mississippi General Power Of Attorney Form Page 5

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SIG ATURE A D ACK OWLEDGME T
____________________________________________
_________________
Your Signature
Date
____________________________________________
Your Name Printed
____________________________________________
Your Address
____________________________________________
Your Telephone Number
CERTIFICATE OF ACK OWLEDGME T OF OTARY PUBLIC
State of Mississippi
County of___________________________
Acknowledged before me this ______day of
(month), _________ (year)
by ______________________________ (name of principal). The affiant is (choose one):
____ personally known to me, or ____ produced the following identification:
.
____________________________________________
Signature of Notary
My commission expires: ________________________
(Seal, if any)

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