STATE OF __________________________
COUNTY OF ________________________
THE UNDERSIGNED AFFIANT, ______________________________________, residing at
_____________________________________________________________________, is of legal age, and does hereby swear and affirm under penalty of perjury that the following is true and accurate, to the best of (his/her) knowledge (list the fact to be attested to):
Executed this _____________ day of ____________, 201(x)____.
SIGNATURE OF AFFIANT
PRINT NAME OF AFFIANT
(FOR NOTARY PUBLIC)
STATE OF _____________________ COUNTY OF ______________________
On the _____________ day of ____________, 201(x)____, before me, ______________________,a Notary Public in and for the above state and county, personally appeared ______________________, known to me (or proved to me on the basis of satisfactory evidence) to be the person who executed the foregoing instrument, and being first duly sworn, such person acknowledged that he/she executed the instrument for the purposes therein contained as his/her free and voluntary act and deed.
Type of Identification Produced: _________________________
WITNESS my hand and official seal.
My Commission Expires: ________________