Executive Summary Page 3

[STATE/COMMONWEALTH] OF [NAME OF STATE]

COUNTY OF [NAME OF COUNTY]

On this, the ______ day of _________________, ________, before me, a Notary Public

for the [STATE/COMMONWEALTH] of [NAME OF STATE], residing in the said County and

State, the undersigned Officer, appeared [GRANTOR], known to me (or satisfactorily proven) to

be the person whose name[S] [IS/ARE] subscribed to the within instrument, and acknowledged

that [HE/SHE/THEY] executed the same for the purposes therein contained.

I hereunder set my hand and official seal.

Notary Public

{SEAL}

MY COMMISSION EXPIRES:

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