Special Power Of Attorney Page 2
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1
2I sign my name to this Special Power of Attorney on:
____________ Day of ____________ Month ____________ Year
__________________________________________________________
Signature
By accepting this appointment and acting under it, I the attorney-in-fact (“Agent”) do hereby assume the
legal responsibilities of an agent.
_____________________________________________________________________Date____________
Signature of Attorney-in-Fact
WITNESS #1) _________________________________
WITNESS #2) _________________________________
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