Florida Affidavit Form

____________________________

attorney in fact signature

____________________________

attorney in fact printed name

State of FLORIDA

County of _______________

The foregoing instrument was acknowledged before me this _____ day of __________20___ by __________________________________________,

as attorney in fact, who q is personally known to me or q has produced a _________________________________as identification on

behalf of _______________________________, the principle.

________________________________

(SEAL)

notary signature

_______________________________

notary printed name

FL-2071-ACK

provides this form pursuant to Florida Statutes §695.25(4)

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