STATE OF ____
COUNTY OF ____
Personally appeared before me, the undersigned authority in and for the said county and state, on this ____ day of ____ , 20 ____, within my jurisdiction, the within named ____, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed in the above and foregoing instrument and acknowledged that he/she/they executed the same in his/her/their representative capacity(ies), and that by his/her/their signature(s) on the instrument, and as the act and deed of the person(s) or entity(ies) upon behalf of which he/she/they acted, executed the above and foregoing instrument, after first having been duly authorized so to do.
My commission expires:
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For issuing guidelines on this form, see Guidelines.