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COUNTY OF ____(2)________)

KNOW ALL YE MEN BY THESE PRESENTS,

That on this _(3)__ day of ______(4)_________, 19_(5)_, personally came and appeared before me ______(6)__________, of __________(7)_______________, known, and known to me, who after being first duly sworn, deposes and says:

(Insert Sworn Statement)

FURTHER AFFIANT SAYETH NOT.

__________(8)____________

SUBSCRIBED TO AND SWORN TO before me this ___(9) day of____(10)____________, 19_(11)_.

_____________(12)__________

NOTARY PUBLIC

My Commission Expires __(13)__