STATE OF _____________) KNOW ALL YE MEN BY THESE PRESENTS, That on this ___ day of _______________, 20__, personally came and appeared before me ________________, of
_________________________, known, and known to me, who after being first duly sworn, deposes and says: FURTHER AFFIANT SAYETH NOT. ______________________ SUBSCRIBED TO AND SWORN TO before me this ___ day of________________, 20__. _______________________ My Commission Expires ____
ss:
COUNTY OF ____________)
(Insert Sworn Statement)
NOTARY PUBLIC
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