AFFIDAVIT

North Carolina County of _______________ , appearing before the undersigned Name of principal notary and being duly sworn, says that: 1. 2.

Affiant

Sworn to (or affirmed) and subscribed before me this the _____ day of _____________, 20___.

(Official Seal) Official Signature of Notary , Notary Public Notary’s printed or typed name My commission expires: