THIS INSTRUMENT HEREBY ACKNOWLEDGES that the undersigned,  , ("affiant"), residing at  is of legal age, and does hereby swear and affirm that the following is true and accurate, to the best of his knowledge, under penalty of perjury:

Signed to this  , .

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STATE OF _____________________COUNTY OF ____________________ In _______________, on the _____________ day of ____________, 19___, before me, a Notary Public in and for the above state and county, personally appeared _____________________________________________, known to me or proved to be the person named in and who executed the foregoing instrument, and being first duly sworn, such person acknowledged that he or she executed said instrument for the purposes therein contained as his or her free and voluntary act and deed.

Type of ID Produced: _________________________

Affiant __ is __ is not personally known to me

_______________________________
NOTARY PUBLIC
My Commission Expires: ________
(SEAL)'