State of __________________
County of _________________
Before the undersigned, an officer duly commissioned by the laws of
____________, on this_____day of _____________, 19____, personally
appeared ______________________________ who having been first duly
sworn depose and say:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Witness:________________ _______________________________
Sworn and subscribed before me this ___day of ___________A.D. 19__
__________________________
__________________________
|
