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State of ________________________ County of _________________________________, ss:
This instrument was acknowledged before me on this _____________ day of _________________
______________ by ______________________________________________________________.
________________________________________
Notary Public
________________________________________
Title (and Rank)
My Commission Expires:____________________
Notary Address
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Printed Name of Notary Republic
Notary Public for the State of ________________________
Residing at: ______________________________________
My Commission Expires: ___________________________
(Notary Seal)

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